DAF 48-107v1

BY ORDER OF THE DEPARTMENT OF AIR FORCE
SECRETARY OF THE AIR FORCE INSTRUCTION 48-107, VOLUME 1
15 DECEMBER 2020
AEROSPACE MEDICINE
EN ROUTE CARE AND AEROMEDICAL

EVACUATION MEDICAL OPERATIONS
COMPLIANCE WITH THIS PUBLICATION IS MANDATORY
ACCESSIBILITY: Publications and forms are available on the e-Publishing website at

www.e-Publishing.af.mil for downloading or ordering.
RELEASABILITY: There are no releasability restrictions on this publication.
OPR: AMC/SGK Certified by: AMC/SG

(Brig Gen Norman S. West)
Supersedes: AFI48-307V1, Pages: 238
8 January 2017
This instruction implements Department of the Air Force Policy Directive (DAFPD) 48-1,
Aerospace & Operational Medicine Enterprise (AOME); supports DAFPD 10-29, Worldwide
Aeromedical Evacuation Operations; and establishes, defines, and implements standards of care
in the Air Force (AF) Aeromedical Evacuation (AE) System. This publication applies to all
military and civilian personnel of the Regular Air Force, Air Force Reserve, and Air National
Guard. This publication does not apply to the United States Space Force. This Instruction
requires the collection and or maintenance of information protected by the Privacy Act of 1974
authorized by Department of Defense (DoD) Instruction (DoDI) 6025.18, Health Insurance
Portability and Accountability Act (HIPAA) Privacy Rule Compliance In DoD Health Care
Programs, and DoDI 8580.02, Security of Individually Identifiable Health Information in DoD
Health Care Programs. The applicable SORN [F044 F SG E, Electronic Medical Records
System] is available at: http://dpclo.defense.gov/Privacy/SORNs.aspx. Ensure all records
created as a result of processes prescribed in this publication are maintained in accordance with
Air Force Instruction (AFI) 33-322, Records Management and Information Governance
Program, and disposed of in accordance with the Air Force Records Disposition Schedule
located in the Air Force Records Management System. Refer recommended changes and
questions about this publication to the OPR using the AF Form 847, Recommendation for
Change of Publication; route AF Forms 847 from the field through the appropriate functional
chain of command. This publication may be supplemented at any level, but all supplements are
routed to the OPR of this publication for coordination prior to certification and approval. The
authorities to waive wing/unit level requirements in this publication are identified with a Tier
(“T-0, T-1, T-2, T-3”) number following the compliance statement. Reference DAFI 33-360,
2 DAFI48-107V1 15 DECEMBER 2020
Publications and Forms Management, for a description of the authorities associated with the Tier
numbers. Submit requests for waivers through the chain of command to the appropriate Tier
waiver approval authority, or alternately for compliance directives that do not have a Tier
identified, to the publication OPR. The use of the name or mark of any specific manufacturer,
commercial product, commodity, or service in this publication does not imply endorsement by
the Air Force. Compliance with the attachments in this publication, with the exception of
Attachment 2, is mandatory.
SUMMARY OF CHANGES
This document has been substantially revised and needs to be completely reviewed. Major
changes include updating: validating flight surgeon responsibilities throughout, patient regulating
in chapter 3; nursing considerations in chapter 8; patient safety program in chapter 9; and
medical logistics in chapter 12. Significant USTRANSCOM information was removed and the
user is referred to USTRANSCOM guidelines.
Chapter 1—PROGRAM OVERVIEW 9
1.1. Mission Description. ................................................................................................ 9
1.2. Purpose..................................................................................................................... 9
1.3. Scope........................................................................................................................ 9
1.4. Standards.................................................................................................................. 10
Chapter 2—OPERATIONAL AND ADMINISTRATIVE ROLES AND

RESPONSIBILITIES 11
2.1. United States Transportation Command. ................................................................. 11
2.2. Air Force Surgeon General (AF/SG). ...................................................................... 11
2.3. Air Mobility Command. .......................................................................................... 11
2.4. Pacific Air Forces Command Surgeon (PACAF/SG). ............................................. 16
2.5. United States Air Forces Europe-Air Forces Africa Command (USAFE-
AFAFRICA/SG). ..................................................................................................... 16
2.6. Wing Commander. ................................................................................................... 16
2.7. Flight Surgeon.......................................................................................................... 17
2.8. Patient Staging and En Route Patient Stage............................................................. 18
2.9. Contingency Operations. ......................................................................................... 18
2.10. AE Squadron UTC Structure. .................................................................................. 19
2.11. Force Protection. ...................................................................................................... 20

DAFI48-107V1 15 DECEMBER 2020 3
Chapter 3—REQUESTING AE PATIENT MOVEMENT THROUGH PMRC 22
3.1. Patient Movement Considerations. .......................................................................... 22
3.2. Requesting AE for Patients. ..................................................................................... 22
3.3. Local Flight Surgeon. .............................................................................................. 23
3.4. Submitting a PMR for Validation and Movement. .................................................. 24
Table 3.1. Minimum Requirements to Enter a Patient Movement Request. ............................. 24
3.5. Determining Movement Precedence. ....................................................................... 26
3.6. Special Category Patients. ....................................................................................... 27
3.7. Determining Patient Classification. ......................................................................... 27
Table 3.2. Patient Classification. .............................................................................................. 29
3.8. PMR Validation and Acceptance for Flight............................................................. 30
3.9. Patient Movement Operations.................................................................................. 30
3.10. Validating Flight Surgeon (VFS). ............................................................................ 31
3.11. TRAC2ES. ............................................................................................................... 32
Chapter 4—ORIGINATING AND DESTINATION FACILITY 33
4.1. General Information. ................................................................................................ 33
4.2. MTFs and ERPS responsibilities. ............................................................................ 33
4.3. Theater Medical Data Store. .................................................................................... 33
4.4. Travel Authorizations. ............................................................................................. 33
Table 4.1. TCSG. ...................................................................................................................... 33
4.5. Transportation. ......................................................................................................... 34
4.6. Documentation and Transfer of Patient Records. .................................................... 34
4.7. Mission Coordination. ............................................................................................. 35
4.8. Accountability. ......................................................................................................... 35
4.9. Entry Requirements. ................................................................................................ 35
4.10. Patient Safety Events/Near Miss Events. ................................................................. 35
4.11. RON Patients. .......................................................................................................... 35
4.12. MTF Support Requirements for the Co-Located ERPS........................................... 35

Chapter 5—EN ROUTE PATIENT STAGING SYSTEM (ERPSS) 38
5.1. En Route Patient Stage (Facility)............................................................................. 38
5.2. Roles and Responsibilities. ...................................................................................... 38
5.3. Vehicles. .................................................................................................................. 39
5.4. Interface with MTFs/Other Agencies. ..................................................................... 39
5.5. Training.................................................................................................................... 40
5.6. Expeditionary Medical Logistics. ............................................................................ 40
5.7. ERPS Facility Administration.................................................................................. 40
5.8. Mission Launch and Recovery................................................................................. 41
5.9. Reports and Communication.................................................................................... 42
Chapter 6—PATIENT PREPARATION 43
6.1. Overview of patient preparation. ............................................................................. 43
6.2. Litters. ...................................................................................................................... 43
6.3. Clothing the Patient. ................................................................................................ 43
6.4. Equipment and Supplies. ......................................................................................... 44
6.5. General considerations for attendants. ..................................................................... 44
6.6. Baggage. .................................................................................................................. 45
6.7. Anti-hijacking. ......................................................................................................... 46
6.8. Valuables. ................................................................................................................ 47
6.9. Patient Identification. ............................................................................................... 48
6.10. Weapons................................................................................................................... 48
6.11. Nutrition and meals. ................................................................................................. 49
Table 6.1. Planning Patient Meals and Snacks. ........................................................................ 50
6.12. Patient Briefings. ..................................................................................................... 52
Chapter 7—FLIGHT PHYSIOLOGY AND STRESSES OF FLIGHT 54
7.1. Flight Environment. ................................................................................................. 54
7.2. Gas Laws.................................................................................................................. 54
7.3. Physiological Stressors of Flight. ............................................................................ 55

Chapter 8—PATIENT CARE RESPONSIBILITIES 59
8.1. Aeromedical Evacuation Clinical Protocols. ........................................................... 59
8.2. Preflight Assessment and Report. ............................................................................ 59
8.3. General Nursing Care. ............................................................................................. 61
8.4. Airway and Respiratory Management. .................................................................... 62
Table 8.1. Glasgow Coma Scale. .............................................................................................. 63
Table 8.2. O2 Delivery Methods. .............................................................................................. 65
Table 8.3. Oxygen Requirements for Low Hemoglobin States. ............................................... 66
Table 8.4. Conversion for In-flight Oxygen Administration. ................................................... 67
8.5. Hypoxia.................................................................................................................... 75
Table 8.5. Signs and Symptoms of Hypoxia............................................................................. 77
8.6. Pulmonary Embolism (PE)/VTE Events During AE. .............................................. 78
8.7. Cardiovascular Management. .................................................................................. 79
8.8. Shock Management.................................................................................................. 81
8.9. Burn Management.................................................................................................... 84
8.10. Hematological and Endocrine Management. ........................................................... 88
8.11. Decompression Sickness.......................................................................................... 92
8.12. Neurological Management. ...................................................................................... 93
Table 8.6. Management and Treatment Considerations/Recommendations for TBI and

Increased ICP. .......................................................................................................... 94
Table 8.7. ICP and Cerebral Perfusion Pressure (CPP) Parameters. ........................................ 95
Table 8.8. MACE - Red Flags. ................................................................................................. 96
Table 8.9. Considerations for CNS-injured/Neurologic Disease/Comatose/Vented Patient. ... 97
Table 8.10. Seizure Precaution and Treatment. .......................................................................... 99
8.13. Musculo-Skeletal System/Wound Disorders/Injuries. ............................................. 100
8.14. Wound Management. ............................................................................................... 102
8.15. Medical Devices. ..................................................................................................... 104
8.16. Eyes, Ears, Nose, and Maxillofacial Management. ................................................. 106
8.17. Gastrointestinal (GI)/Genitourinary/Tube Management. ......................................... 112

8.18. Obstetrics (OB)/In-Flight Child Birth Management. ............................................... 117
8.19. Pediatric Management. ............................................................................................ 123
8.20. Mental Health Patient Management......................................................................... 129
8.21. Pain Management. ................................................................................................... 136
Figure 8.1. Dermal Segmentation (Dermatome Map). ............................................................... 143
Table 8.11. Motor Activity Assessment Scale (MAAS) Sedation Scoring System. ................... 147
8.22. Medications.............................................................................................................. 149
8.23. IV Therapy. .............................................................................................................. 156
8.24. Management/Administration of Blood and Blood Products. ................................... 157
8.25. Infection Control. ..................................................................................................... 160
Chapter 9—PATIENT MOVEMENT PATIENT SAFETY PROGRAM (PMPS) 172
9.1. General. .................................................................................................................... 172
9.2. Objectives: ............................................................................................................... 172
9.3. Responsibilities. ....................................................................................................... 172
9.4. Patient Movement Event/Near Miss Reporting Process. ......................................... 178
9.5. Event Degree of Harm. ............................................................................................ 179
Table 9.1. Degree of Harm. ...................................................................................................... 179
Table 9.2. Duration of Harm. .................................................................................................... 180
9.6. Event Categories. ..................................................................................................... 180
Table 9.3. Reporting Changes. .................................................................................................. 180
9.7. Reporting Events Involving Unexpected Death, Permanent Harm, or Severe

Temporary Harm...................................................................................................... 181
9.8. PM Comprehensive Systematic Analysis (CSA). .................................................... 181
9.9. PM External Patient Safety Investigation (EPSI). ................................................... 182
9.10. Clinical Operations Patient Safety Alert (COPSA). ................................................ 183
Chapter 10—MISSION IRREGULARITIES 184
10.1. Cabin Altitude Restriction. ...................................................................................... 184
10.2. Medical Emergency/Change in Patient Status. ........................................................ 184
10.3. Death In-flight/Do Not Resuscitate (DNR). ............................................................ 185

10.4. Mission Delays. ....................................................................................................... 185
10.5. Medical Delays. ....................................................................................................... 186
10.6. In-Flight Refueling Considerations.......................................................................... 186
10.7. En Route Diversions. ............................................................................................... 186
10.8. Scheduled and Unscheduled RONs. ........................................................................ 186
10.9. Patients Requesting Release from the Aeromedical Evacuation System................. 187
10.10. Prisoner-patients. ..................................................................................................... 187
10.11. Unaccompanied Minors/Incompetent Patients. ....................................................... 188
10.12. Conflict Resolutions. ............................................................................................... 188
10.13. Credentials Considerations. ..................................................................................... 188
10.14. Engine Running Off/On Loads (ERO). ................................................................... 188
10.15. No and Low Light Conditions. ................................................................................ 189
10.16. Service Animals and Emotional Support Animals. ................................................. 189
10.17. Military/Government Working Dogs. ...................................................................... 190
10.18. Passenger Requiring Medical Attention. ................................................................. 190
Chapter 11—POST-MISSION PROCEDURES 191
11.1. Post-Mission Responsibilities. ................................................................................. 191
11.2. AE Patient and Customer Satisfaction Survey. ........................................................ 191
11.3. AMC Reviews And Analyzes AE System Surveys And Report Trends. ................ 192
Chapter 12—MEDICAL LOGISTICS 193
12.1. MEFPAK. ................................................................................................................ 193
12.2. PMI Asset Tracking System (PMI-ATS). ................................................................ 193
12.3. PMI Levels. .............................................................................................................. 193
12.4. Equipment Responsibility. ....................................................................................... 194
12.5. Equipment Malfunction/Failure. .............................................................................. 195
12.6. Procurement of Medical Materiel. ........................................................................... 196
12.7. ERPS Medical Logistics. ......................................................................................... 197
12.8. Recommending Allowance Standard Changes. ....................................................... 197
Attachment 1—GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION 198

Attachment 2—HELPFUL RESOURCES 210
Attachment 3—NON-MEDICAL, FAMILY OR NON-MILITARY ATTENDANT

INFORMATIONAL SHEET 212
Attachment 4—MEDICAL ATTENDANT DUTY LIST 213
Attachment 5—NON-MEDICAL ATTENDANT DUTY LIST (MILITARY) 215
Attachment 6—PATIENT PREP CHECKLIST 216
Attachment 7—PATIENT MOVEMENT INPATIENT HANDOFF CHECKLIST –

FRONT 217
Attachment 8—PATIENT MOVEMENT OUTPATIENT HAND-OFF CHECKLIST 219
Attachment 9—BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK BY

LEVEL OF RISK 220
Attachment 10—BURN CENTER REFERRAL CRITERIA 222
Attachment 11—MILITARY ACUTE CONCUSSION EVALUATION 224
Attachment 12—ALCOHOL WITHDRAWAL ASSESSMENT SCORING GUIDELINES 226
Attachment 13—PAIN ASSESSMENT SCALES 227
Attachment 14—AIRCRAFT AIRFLOW 230
Attachment 15—RESPIRATORY DISEASE MISSION PLANNING ALGORITHM 232
Attachment 16—PATIENT MOVEMENT PATIENT SAFETY EVENT REPORTING

EXAMPLES 233
Attachment 17—AE PATIENT AND CUSTOMER SATISFACTION SURVEY 236
Attachment 18—EN ROUTE CARE EQUIPMENT MALFUNCTION REPORT TAG 237

Chapter 1
PROGRAM OVERVIEW
1.1. Mission Description. AE includes all elements of medical care, support, treatment, staging
and transport, from the point at which a request for movement has been received, through the
final destination for definitive care. AE provides time-sensitive movement of casualties to and
between medical treatment facilities (MTFs), using USAF and/or contracted aircraft with
medical aircrew trained explicitly for the mission. AE forces can operate as far forward as
aircraft are able to conduct air operations, across the full range of military operations, and in all
operating environments. Specialty medical teams may be assigned to work with the AE aircrew
to support patients requiring more intensive patient care. The AE system is a subset of the overall
patient movement system. Patient movement begins as soon as a patient receives care, which
may be at point of injury. Patient staging has several connotations and denotes all patient staging
missions, in garrison and expeditionary. The ERPS is a specific, Unit Type Code (UTC) staging
facility. The En Route Patient Staging System (ERPSS) denotes the global system. There are also
facilities that may not have a designated ERPS UTC, in which patient staging also occurs.
Patient staging provides medical personnel and equipment necessary for 24-hour patient staging
operations, patient transportation to/from aircraft, and administrative processes for tracking
patients transiting the AE system worldwide.
1.2. Purpose. This AFI provides clinical information and guidelines to promote safe and
effective en route care for DoD beneficiaries and other authorized, or designated patients. Care is
provided by en route care personnel in the patient staging and inflight environment. Information
in this AFI provides guidance for patient airlift operations, but is not intended to be used as a
substitute for sound clinical judgment.
1.3. Scope.
1.3.1. Staging facilities facilitate any necessary inpatient medical-surgical care. The
supporting MTF with required capability cares for critically ill or inpatient mental health
patients or on a short-term basis by an En Route Critical Care (ERCC) team (e.g., critical
care air transport team [CCATT]; burn team; neonatal intensive care team) at the staging
facility for patients awaiting airlift. ERCC system encompasses several critical care teams
(e.g., burn, neonatal, lung, pediatric, trauma). Provisions are secured to address support
services and additional clinical care required by patients in the staging facility due to patient
condition changes, or mission delays/cancellations. The primary supporting MTF generally
provides all clinical, surgical, and ancillary support required for patients in the staging
facility regardless of size.
1.3.2. Aeromedical Evacuation Crew Members (AECM). AECMs provide specialized
inpatient medical-surgical care capability with basic life support (BLS) and advanced cardiac
life support (ACLS) resuscitative capability while contacting the mission Command and
Control (C2) for further medical direction. During mission execution, AECM’s clinical
practice is under the medical direction of the validating flight surgeon (VFS). Mission
requirements drive the use of specialty augmented medical teams and medical attendants
(MA). Note: To preserve life, limb, or eyesight, in an emergency, when no physician is
present or cannot be contacted, AECMs and/or medical personnel follow guidance outlined
within this instruction. The AECM notifies the appropriate Patient Movement Requirements
Center (PMRC) of any treatment performed outside a patient’s written orders as soon as
operationally feasible.
1.3.3. Medical personnel in the AE system provide care based upon their specialty, scope of
practice, specific core competencies, level of knowledge, training, and skills.
1.4. Standards.
1.4.1. Standards of Care (SOC): The AE and patient staging environments present the health
care provider with unique challenges. The stresses of flight are considered in patient
preparation. The SOC in the air are adapted to the aircraft’s capabilities and limitations, and
the in-flight environment. Refer to DAFPD 46-1, Nursing Services.
1.4.2. Standards of Performance: The standards of professional performance are the
expected level of function based on education, level of experience and criteria of the current
position requirements. The baseline clinical standards of care are inpatient medical-surgical
care. Air Mobility Command (AMC) Command Surgeon (SG) has adopted Clinical Skills
Plus (formally known as Mosby Online), Lippincott, Air and Surface Transport Nurses
Association (ASTNA) standards of professional performance (when operationally feasible)
and the National Registry for Emergency Medical Technicians. Refer to AFI 46-101, Nursing
Services and Operations.
1.4.3. Standards of Practice: Standards of practice focus on the medical personnel and their
competency, experience, and education. The primary goal of the AE system is to meet the
perceived, actual, or potential health needs of the patient, while maintaining the continuum of
care. Refer to DAFPD 46-1
1.4.4. Aeromedical Evacuation Clinical Protocols. AE clinical protocols (AECP) are
evidence based clinical protocols that provide standard orders in specific clinical scenarios.
AECPs are located on the AMC/SG Sharepoint and the electronic flight bag.
Chapter 2
OPERATIONAL AND ADMINISTRATIVE ROLES AND RESPONSIBILITIES
2.1. United States Transportation Command. Is the DoD single manager for implementing
policy and standardizing procedures and automated information system requirements for global
patient movement (PM); provides global PM in coordination with the geographic combatant
commanders (GCC) through the Defense Transportation System and in accordance with DoD
Instruction (DoDI) 6000.11, Patient Movement (PM).
2.1.1. United States Transportation Command, Command Surgeon (TCSG) orchestrates
strategic, operational, and tactical guidance on patient movement; guides unity of effort, total
interoperability and standardization between PMRCs to ensure optimal fusion of expediency
and patient safety across the patient movement system. Provides clinical and administrative
support to PMRCs during peacetime and contingency operations and maintains trained
patient movement joint service enablers in accordance with DoDI 6000.11 and
USTRANSCOM guidance.
2.1.2. PMRCs clinically and administratively validate patient movement requests (PMRs)
through the TRANSCOM Regulating and Command and Control Evacuation System
(TRAC2ES) in accordance with DoDI 6000.11. Once validated, a requirement for PM passes
to the respective transportation operations center (maritime, air) or agency to identify
appropriate transportation based on available resources and clinical requirements.
2.1.3. The AE patient safety program (AE PSP) is a subset of the TCSG Patient Movement
Patient Safety (PMPS) program just as AE is a subset of patient movement (PM). The AE
PSP is supports Air Mobility Command’s core mission of AE. It also supports and is aligned
under the TCSG) mission as the DoD single-manager for global PM. The USTRANSCOM
Command Surgeon reports patient safety data directly to the Defense Health Agency.
2.2. Air Force Surgeon General (AF/SG). AF/SG is primarily responsible for developing and
coordinating health care policy for the Air Force Medical Service (AFMS). The AF/SG is also
responsible for coordinating and aligning health care programs and services to integrate with
other Services’ medical departments and the Office of the Assistant Secretary of Defense for
Health Affairs. The AF/SG is also responsible for developing operational medical capabilities to
support the warfighter and for the delivery of operational clinical services under the operational
control of the combatant commands for the en route care system.
2.3. Air Mobility Command. AMC serves as the lead major command (MAJCOM) for AE. As
outlined in DAFPD 10-21, Rapid Global Mobility, AMC coordinates with the other commands
(e.g., AF Reserve Command {AFRC} and Air National Guard {ANG}) involved in air mobility
operations, to include AE, and manages those processes designated to enable the interoperability
of air mobility forces regardless of the command. AMC maintains clear, detailed, and
accountable standards in this mission area to ensure efficient employment and interoperability.
AMC works with MAJCOMs to ensure appropriate forces are organized, trained, and equipped
to perform the AE mission across the full spectrum of operations to meet global AE
requirements. All AE forces comply with lead MAJCOM readiness standards addressing
operational and clinical requirements. Aeromedical Evacuation policies and procedures are fully
coordinated through AMC and supporting MAJCOMs to ensure needs are identified and policies
and procedures are thoroughly formulated.
2.3.1. AMC Command Surgeon (AMC/SG). Serves as the AE program medical director,
responsible for the overall supervision, safety, and quality of medical care provided
worldwide by the AE system, En Route Critical Care (ERCC), and patient staging personnel.
AMC/SG establishes clinical practice standards and clinical training requirements. AMC/SG
collaborates with AMC Directorate of Operations (AMC/A3) to ensure medical/clinical
operations and aircrew operations are fully integrated.
2.3.1.1. AMC En Route Medical Care Division (AMC/SGK). Represents the AMC/SG
regarding AE clinical programs and activities. Serves as a clinical advisor to all AMC,
ANG, and AF Reserve (AFR) AE/patient movement units. Establishes and maintains
clinical policy and procedures for AE and the clinical standardization and training of
medical personnel assigned to AE/patient movement duties. Responsible for and manages
the AE Patient Safety and ERCC team programs. SGK provides necessary clinical inputs
to include special interest items, allowance standards substitutions, and crew complement
to AMC/A3 to ensure current medical/clinical operations are incorporated into
operational processes. Maintains oversight and guidance of the medical/clinical
operations of AE and ensures integration with global patient movement processes in the
4X (medical and health services) publications series.
2.3.1.1.1. Guides clinical operations through release of clinical information
impacting AE through the use of policies, clinical operations patient safety alert
(COPSA), guidance memorandums, and emergency care research institute
notifications. Notifications are sent to the applicable leadership for dissemination.
COPSAs are maintained on the electronic flight book (EFB), the medical read file for
patient staging personnel and AMC/A3 and AMC/SG site (reference Attachment 2,
A2.1.1).
2.3.1.1.2. Manages the AE COPSAs to facilitate the timely communication of AE-
focused clinical information and lessons learned from AMC/SG to the global AE
community. The COPSA carries the same weight as the flight crew information file
(FCIF). The operational and medical unit commanders ensures widest dissemination
and implementation of applicable recommendations. AECMs and other ERCC
personnel read and follow the recommendations contained in the COPSAs.
2.3.1.1.3. Defines the requirements for the clinical training levels identified in
AFMAN 11-2AEV1, Aircrew Standardization/Evaluation Program.
2.3.1.1.4. Creates standardized clinical scenarios to support specialized inpatient
medical surgical care capabilities.
2.3.1.1.5. Provides clinical scenarios for MAJCOM and Joint Staff directed
exercises.
2.3.1.1.6. Orchestrates clinical planning for Humanitarian Assistance and Disaster
Response activities.
2.3.1.1.7. Collaborates on medical equipment requirements for developmental and
commercial-off-the-shelf items that supports the MAJCOM Safe-to-Fly program.
2.3.1.1.8. Provides clinical consultant services to AMC Medical Support Division

(SGS) for medical information systems (e.g., electronic health record) for en route
care.
2.3.1.1.9. Collaborates with AMC Modernization and Research Division (SGR) on
clinical equipment, research gaps and modernization of the current AE portfolio.
2.3.1.2. AMC Medical and Aeromedical Evacuation, Readiness and Plans Division
(AMC/SGX). Oversees policy, guidance, strategic resource planning, mission capability
reporting and expeditionary operations. Develops and monitors Theater Aeromedical
Evacuation System (TAES) ground support UTCs in the Aeromedical Evacuation and
Patient Staging Course.
2.3.1.2.1. Supervises Manpower and Equipment Force Packaging System
(MEFPAK) Responsible Agency (MRA) duties covering en route medical care,
AFMS-owned AE UTCs, and war reserve materiel (WRM) assets. Establishes
policies, directives, and procedures for the medical readiness programs at subordinate
units. Develops requirements for research and development of medical equipment
proposed for and used in the AE. Directs AMC medical operations, deployments,
contingency, disaster planning, and use of command medical assets in exercises.
2.3.1.2.2. AMC/SGXM is the patient movement item (PMI) program execution
office and is responsible for administering the PMI program. Responsible for AMC
medical readiness and liaison with the MTFs, MAJCOMs, AFMS, combatant
command (CCMD), and partner agencies. Global Force Functional Area Manager for
AE Support UTCs (e.g., CCATT, ERPSS), and recommends sourcing solutions to the
TCSG to meet Combatant Commander (CCDR) requests for forces. Training waiver
authority for MEFPAK training requirements as described in AFI 41-106, Air Force
Medical Readiness Program.
2.3.1.2.3. Assists in the development of component-level war planning and AE
staging planning support for TCSG in support of Combatant Command (CCMD)
Operational Plans (OPLANS) and Concept Plans (CONPLANS) under the authority
of Joint Strategic Capabilities Plan planning tasks. Identifies AFMS-owned AE
capabilities based on available resources. Manages the Safe-to-Fly program for AE
equipment to be used on Air Force fixed and rotary wing aircraft.
2.3.1.3. AMC Aerospace Medicine Division (AMC/SGP). Advises and assists the
AMC/SG in the interpretation and implementation of the AMC aerospace medicine
program and operational medical policies. Serves as waiver authority for aeromedical
flight physical standards in AMC and coordinates aeromedical waivers for those cases
requiring specialist review. Member of AMC threat working group. Assesses medical
threats for worldwide deployment locations and provides risk assessments for the AMC
Threat Working Group. Develops policy for public health infection and communicable
disease control for AE operations.
2.3.1.4. AMC Medical Support Division (AMC/SGS). Develops, coordinates, and
advocates AMC/SG inputs into the AFMS strategic resourcing process including Medical
Planning and Programming Guidance and Program Objective Memorandum. Develops
and executes annual budget for directorate operations MEFPAK mission. Provides
budget analyst function for global AE financial transactions including funding worldwide
patient movements on military aircraft and civilian air ambulances. Also collaborates
with TCSG to process civilian insurance reimbursements to the government for
beneficiary patient travel. Advises the AMC/SG on establishing policy and guidance for
the development and deployment of command-unique medical data and communication
systems. Provides installation, operations, security training, and maintenance services for
the AF en route electronic health record (EHR). Provides consultant services to field
activities for medical information systems. Manages technology and processes for the AE
EHR Program, including resourcing and device technology evolution. Validates and
processes military personnel appropriation (MPA) man-day requests using the current
using the Manpower MPA Man-day Management System (M4S) for ANG and AFR
medical personnel to support AMC/RegAF requirements.
2.3.1.5. AMC Modernization and Research Division (AMC/SGR). Develops, maintains,
advances, and pursues funding for the AMC medical modernization portfolio. Leads AE
research and development efforts across the AFMS. Articulates research needs and
capability gaps with internal and external research partners, defines and articulates the
process for users to submit research and technology solutions, and accurately categorizes
initiatives with distinction between knowledge enhancement and technology
development. Identifies gaps in doctrine, organization, training, materiel, leadership, and
education, personnel, and facilities. Leads development activities of the EHR.
2.3.2. AMC Directorate of Operations (AMC/A3). Defines roles and responsibilities of the
A3 in the AE system.
2.3.2.1. AMC Deputy Director, AE Operations. Senior AE authority to Directorate of
Operations and provides executive oversight for global Total Force AE operations.
Directs efforts to include AE funding, manning, training, and strategic direction for
AMC/A3 assigned divisions and AE squadrons. Interfaces with joint, North Atlantic
Treaty Organization (NATO), and coalition forces to develop worldwide AE doctrine and
policy. Provides AE expertise to Headquarters United States Air Force, MAJCOMs, and
Numbered Air Force (NAF). Co-chair of the AE Board.
2.3.2.2. AMC Aeromedical Evacuation Operations Branch. Provides policy, procedures,
and concepts of operations for all Aeromedical Evacuation Squadrons (AES). Develops
ground operations training programs, standards, and inspection guidelines for global AE.
Interfaces with joint, special operations, NATO, and coalition policy makers to
standardize AE operations worldwide. Serves as the Global Force Functional Area
Manager for AE (non AFMS) UTCs and recommends sourcing solutions to the joint
force provider to meet CCDR requests for forces. Identifies AE unit capabilities based on
available resources (active duty, AFR, and ANG). Appointed by the AMC/A3 as the
program element monitor for Program Element: 41133F – Aeromedical Evacuation.
Coordinates with AMC/SG for funding and associated medical resource letter equipment
laydown for AE squadrons. Implements changes to the medical resource letter for
personnel UTCs assigned to AE squadrons. Establishes doctrine and policy to support AE
operations, in coordination with AMC/SG and owning MAJCOM/A3s. Establishes and
disseminates operational training and assessment policy. Advocates to obtain and allocate
resources for AE equipment and training. Executes AE Lead Command operational
functions.
2.3.2.3. AMC Aeromedical Evacuation Standardization and Evaluation (AMC/A3VM).

Implements and manages AE specific issues for the flight manuals and technical order
program for various Air Force weapon systems. Provides standardized operating
guidance for aircrews to ensure publications are readily available to meet all aircrew and
mission requirements. Observes operational missions and performs No-Notice flight
evaluations to provide feedback on the health of the AE system. Maintains current,
universal qualification status in respective crew position to fulfill MAJCOM job
responsibilities, administers required evaluations, and provides competent and current
expertise on respective aircraft and aircrew-related issues. Develops and authors master
question file for each crew position for in-unit closed book testing in accordance with
AFI 11-202V2, Aircrew Standardization and Evaluation Program. Coordinates with
AMC/SG on development of new aeromedical evacuation equipment, assesses
operational risk for use on AMC aircraft, and provides recommendations for medical
equipment air worthiness testing. Provides guidance on medical equipment to
aeromedical evacuation crewmembers. Approves waivers for non-certified/non-standard
medical equipment required for patient moves.
2.3.2.4. AMC Aeromedical Evacuation Training and Operations (AMC/A3TM).
Establishes policies and procedures for AECM aircrew operational training and
operations. This includes the preparation and update of AMC training publications,
qualification programs, and continuation training. Training includes both peacetime and
wartime requirements and ensures a global approach and interoperability with the
worldwide AE system to include high consequence infectious disease transport
capabilities. Formulates and interprets policy and procedures for AE units which cannot
be addressed at the local wing level. Participates in Unit Effectiveness Inspections to
validate Wing compliance with training programs. Participates in frequent AE flights
performing training and basic crewmember duties. Provides functional expertise to
aeromedical evacuation units. Represents the AMC/A3TM Division Chief regarding AE
training policy. Coordinates war readiness training and equipment issues with AMC
Medical Equipment Force Packaging (AMC/SGXM/SGXO) and coordinates clinical
training requirements with AMC/SGK.
2.3.2.5. AMC Joint Exercises (AMC/A3Y). Focal point for command support and
participation in joint and national exercises and provides foundational exercise inputs,
establishes the framework for leadership decisions on the Mobility Air Force’s Exercise
Weight of Effort, and validates unique exercise plans and orders for exercise during the
year. Exercises include, but are not limited to, ULTIMATE FOCUS (headquarter crisis
battle staff function), ULTIMATE REACH (strategic airdrop), and Theater AE system
exercises at the Joint Readiness Training Center.
2.3.3. The AMC Component-MAJCOM includes its commander, AMC/CC, identified staff,
the 618th Air and Space Operations Center, and all assigned forces. A3X, A5X and the Air
Operations Center (AOC), support the AMC/CC through the full range of air mobility
operations at the operational and tactical levels in world-wide operations.
2.3.3.1. AMC A3X and A5X branches function as the execution and contingency
planners, of the AMC Component MAJCOM; they are also the AF component within
AMC which executes Commander United States Transportation Command
(USTRANSCOM/CC) assigned missions. A3X and A5X plan, coordinates and direct AE
execution for real-world and exercise requirements and coordinate laydown of AE forces.
A3X and A5X develops component-level war planning and AE planning support for
USTRANSCOM in support of CCMD OPLANS and CONPLANS under the authority of
Joint Strategic Capabilities Plan planning tasks. A3X and A5X collaborate with
USTRANSCOM and AMC to identify AE capabilities based on available assets. A3X
and A5X collaborate with PACAF and USAFE A3 for AE forces to coordinate AE
support for real world and AMC-sponsored exercise requirements and
OPLAN/CONPLAN support.
2.3.3.2. The AMC/CC retains responsibility as Commander of Air Force Forces
(COMAFFOR). The COMAFFOR delegates operational control to AMC/DA3 and
tactical control to 618 Air and Space Operations Center/CC of the AMC forces and Air
Reserve Component (ARC) forces available for allocation and execution.
2.3.3.3. 618th Air and Space Operations Center. The 618 Air and Space Operations
Center is the planning, tasking, executing, and assessing agency for USTRANSCOM
validated patient movement requirements. The 618 Air and Space Operations Center
provides centralized C2 of all AMC air mobility operations around the globe and acts as
the single point of contact for AMC operations. A critical enabling feature of 618 Air and
Space Operations Center is its robust C2 system, which allows 618 Air and Space
Operations Center to schedule, task, manage, coordinate, control, and execute air
mobility missions globally.
2.4. Pacific Air Forces Command Surgeon (PACAF/SG). PACAF/SG is the theater Air
Component Surgeon for United States Indo-Pacific Command (USINDOPACOM) and has
clinical oversight of the AE mission for the USINDOPACOM theater to include US Forces
Korea and US Forces Japan.
2.5. United States Air Forces Europe-Air Forces Africa Command (USAFE-
AFAFRICA/SG). USAFE-AFAFRICA/SG is the theater Air Component Surgeon for United
States European Command (USEUCOM) and United States African Command (USAFRICOM)
and has clinical oversight of the AE mission for the European and African theaters.
2.6. Wing Commander. (or the individual performing the functions of a wing commander
equivalent). Exercises command over AE units and personnel in their wing. Establishes AE goals
and programs within the wing in support of the wing’s objectives. Establishes plans, policies,
and procedures necessary to the proper conduct of wing affairs especially those which facilitate
the Medical Group (MDG), AES, and Patient Staging operations within the Wing. Wing
Commander ensures the safety of personnel and equipment to include those en route care assets
deployed to the Wing, through an active and aggressive safety education and inspection program.
2.6.1. Operations Group Commander (OG/CC). The primary mission of the operations group
(OG) is to manage flying operations within the assigned wing. AESs are assigned to the OG.
The OG typically has an AE Standardization and Evaluation (Stan/Eval) function as well as
an operations support squadron to provide flying support to AES’s in areas of airfield
operations, aircrew training, weather, intelligence, host aviation resource management and
current operations.
2.6.2. Aeromedical Evacuation Squadron (AES). Plans, directs, organizes, coordinates, and
evaluates all activities in support of AE training/operational missions and the TAES. AES
Commander advises the OG/CC on major policies and procedures affecting AE and the
TAES. Provides guidance and direction to the DO, chief nurse executive, superintendent, and
ensures all flights function optimally including operations, operations support, training,
clinical management as well as stan/eval and the commander’s support staff. AES/CCs
incorporates clinical information released by AMC/SG into a medical read file which is
maintained in FCIF Volume I - Part B in accordance with AFI 11-202V2_AMCSUP,
Aircrew Standardization and Evaluation Program; AECMs reviews and initials the medical
read file as outlined in the unit Go/No Go process. AES/CCs maintain unit readiness in
accordance with AFMAN 10-2909, Aeromedical Evacuation (AE) Equipment Standards.
2.6.3. MDG. Provides outpatient and/or inpatient medical care to DoD beneficiaries.
Provides medical support to the AE system for patient staging and/or unscheduled remain
overnight (RON) missions. Maintains unit readiness in accordance with AFI 41-106 and
postures Air Force UTC in support of the DoD medical mission.
2.6.4. Staging facility aeromedical staging squadrons. Provides coordination,
communication, and transportation 24/7 to support medical care of patients transiting the
aeromedical evacuation system. Ensures patients are medically prepared for flight. The
peacetime mission is to conduct a comprehensive training program to maximize wartime
readiness.
2.6.5. Chief Nurse Executive (CNE). Patient staging, AE squadron, or expeditionary AE
flight designate a CNE in accordance with AFI 46-101.
2.6.5.1. The CNE administers, directs, and evaluates nursing service activities. Evaluates
the quality of nursing care provided to AE patients in accordance with AFI 44-119,
Medical Quality Operations and implements programs to improve patient care delivery
and organizational efficiency. Performs roles and responsibilities and functions in
accordance with AFI 46-101. The CNE advises the commander on nursing matters and
clinical care and quality in AE and/or patient staging settings.
2.6.5.2. The CNE coordinates clinical training required by AFIs and clinical
management and staff development programs to promote nursing practice proficiency.
Nursing personnel are required to have sufficient professional skill to provide the
required medical support consistent with patient numbers, classification, and condition as
determined by the CNE. The CNE establishes clinical training levels in accordance with
AFMAN 11-2AEV1.
2.6.5.3. The CNE in an AE squadron or expeditionary AE flight reduces or increases the
crew complement based on operational risk management (ORM) and patient acuity in
accordance with AFMAN 11-2AEV3, Aeromedical Evacuation Operations Procedures.
in accordance with AFPAM 10-1403; Air Mobility Planning Factors, for contingency
planning only, the patient/crew ratio should be no greater than 10:1 (10 patients to each
AECM). The medical crew director (MCD) and charge medical technician are counted as
AECMs.
2.7. Flight Surgeon. The flight surgeon is responsible for continued medical treatment of AE
patients to include reassessment and clearance of patients prior to loading patients on an AE
mission. In contingencies, the ERPS flight surgeon serves as an AE consultant and triage officer.
If needed, the flight surgeon serves as medical provider for medical personnel and aircrew. Due
to the joint operational nature of contingencies, the flight surgeon may be placed in a role of
educator for other physicians attempting to utilize the AE system.
2.8. Patient Staging and En Route Patient Stage. ERPS provides support and continuity of
medical care for patient movement and serves as an integral link in the global PM system. The
ERPS, regardless of facility size, provides medical personnel and equipment necessary for 24-
hour patient staging operations, patient transportation to/from aircraft, and administrative
processes for tracking patients transiting the AE system worldwide. It is designed for short-term
inpatient medical-surgical nursing care and limited emergent intervention (reference Chapter 5
and ERPS Tactics, Techniques, and Procedures [TTP] 3.42.57, En Route Patent Staging System).
The USTRANSCOM Patient Movement Requirements Center (TPMRC) or applicable C2
agency, coordinates the ground transportation of the ERCC patient and team. The AE Operations
Team (AEOT) and ERPSS collaborates with the TPMRC to ensure the ERCC team is recovered
and returned to either the AEOT or lodging as required.
2.8.1. ERPSS-10 (FFEPS) is deployed in accordance with AFTTP 3-42.57. Note: If the
ERPSS-10 is tasked, the AE Communications Team (FFQCR) UTC is tasked to provide
manpower for communication operations.
2.8.2. The ERPSS-provider (FFPPS), ERPSS-50 (FFFPS) and ERPSS-100 (FFPSS) are
deployed in accordance with AFTTP 3-42.57.
2.8.3. Guidance on administrative control for AFR and ANG personnel is provided in Air
Force Doctrine, Volume 1 and AFI 38-101, Manpower and Organization.
2.9. Contingency Operations.
2.9.1. Air Operations Center (AOC). The AOC provides operational-level command and
control of air, space, and cyberspace operations (reference AFI 13-1AOCV3, Operational
Procedures-Air Operations Center).
2.9.2. Air Mobility Division (AMD). The AMD is a division within AOC. The AMD chief
and personnel plan, coordinate, task and execute the air mobility mission in support of the
AOC air, space, and cyberspace operation planning and execution processes. The AMD
consists of four teams: airlift control team, air refueling control team, air mobility control
team and aeromedical evacuation control team. The Aeromedical Evacuation Control Team
(AECT). The AECT is responsible for operational planning, scheduling, and execution of
intra-theater AE missions. The AECT advises and briefs the AMD chief and Director of
Mobility Forces (DIRMOBFOR) on AE issues. The AECT provides command and control of
all theater assigned/attached AE units/operations within the specified area of responsibility
(AOR)/joint operations area (JOA) and assists with inter-theater AE operations arriving,
departing, or transiting the AOR/JOA. The AECT receives validated patient movement
requirements from the PMRC supporting the AOR/JOA. This could be the TPMRC-
America’s (A); TPMRC-East (E) TPMRC-West (W) or joint patient movement requirements
center (JPMRC). The AECT TAES manager coordinates with operational AE planners and
theater medical planners to develop plans and strategies to determine appropriate force lay-
down of AE ground forces and AE crews in support of joint patient movement operations.
The AECT maintains secure and non-secure communications with all AE elements, PMRCs,
operational AE planners, theater medical planners and the deployment distribution operations
center (DDOC). The AECT coordinates closely with the Personnel Recovery Command
Center and joint personnel recovery center to establish/develop integrated AE support

following Personnel Recovery operations. The AECT integrates its activities with the air
refueling control team, air mobility control team, airlift control team, and specialty/support
functions to the maximum extent possible to support the total air mobility effort.
2.9.3. Director of Mobility Forces (DIRMOBFOR). The DIRMOBFOR is responsible for
integrating the total air mobility effort for the COMAFFOR or Joint Forces Air Component
Commander and, in this capacity, provides guidance to the Air Mobility Division to execute
the air mobility mission.
2.9.4. Joint Patient Movement Requirement Center (JPMRC.). The joint activity established
to coordinate the joint patient movement requirements function for a joint task force
operation within a unified command area of responsibility. It coordinates with the theater
patient movement requirement center for intra-theater patient movement and the TPMRC-A
for inter-theater patient movement.
2.10. AE Squadron UTC Structure.
2.10.1. AE Command Squadron (AECS) (FFQCC). In a contingency, the AECS provides C2
of assigned AE Forces in accordance with AFTTP 3-42.52, Aeromedical Evacuation
Command Squadron (FFQCC). The AECS can deploy in advance of other AE UTCs to
establish the support required for AE forces and establishment of a theater aeromedical
evacuation system. The AECS advises the Wing and OG/CCs, as well as other appropriate
personnel/agencies on AE Concept of Operations (CONOPS), doctrine, capabilities, and
requirements. This UTC provides procedural guidance, technical guidance, and management
oversight for assigned, attached, and transiting AE elements.
2.10.2. AE Liaison Team (AELT) (FFQLL). The Air Force AELT provides support between
the forward user and the AE system in the form of operational and clinical interface. This
interface may occur at locations without other AF personnel such as far forward bases and
onboard ship. An AELT may be geographically separated from other AF assets.
2.10.2.1. The flight nurse (FN) provides clinical expertise to facilitate clinical support for
administrative, aircraft specific requirements, equipment requirements and clinical
implications of altitude and stresses of flight. The FN assists the medical units in
preparing AE patients for flight.
2.10.2.2. The Medical Service Corps officer works with the medical unit to move
patients to the correct staging location in a timely manner. The Medical Service Corps
officer coordinates with airlift operations centers and support functions to complete all
AE flight requirements prior to departure. The administrative officer duties are in
accordance with AFTTP 3-42.53, Aeromedical Evacuation Operations Team (FFQNT)
and AEOT Manpower Augmentation Team (FFQCM).
2.10.3. Aeromedical Evacuation Crew (FFQDE). A basic AE crew consists of two FNs and
three aeromedical evacuation technicians (AET) trained to provide in-flight inpatient
medical-surgical level care during air transport using medical equipment certified for use by
airworthiness testing standards in accordance with AFTTP 3-42.5, Aeromedical Evacuation.
Crewmembers are knowledgeable about the stresses of flight, aerospace physiology on
patients, basic trauma skills and patient safety. AECMs are experts on the interface between
aircraft systems and medical equipment to meet clinical care requirements. AECMs also
ensure medical mission management, aircraft safety, configuration, and integration of

medical equipment with aircraft systems. AE crews have limited diagnostic capabilities and
rely on aircraft communications system to contact C2 and the governing PMRC as needed.
2.10.4. AE Operations Team (AEOT) FFQNT. Provides operations and mission
management support to airfields supporting AE. Provides supervision and crew management
for all assigned or transiting AE crews and ERCC teams in accordance with AFTTP 3-42.53.
Manages launch and recovery of missions, interfaces with flight line support agencies, assists
with configuration of aircraft for AE missions, and oversees flight line activities for patient
loading and unloading. Supports AE and ERCC team equipment and resupply. Coordinates
AE crew and ERCC team requirements for life support, billeting, food service,
transportation, finance, and administrative needs (when ERCC teams are attached to the
AES). May be augmented with an AEOT Augmentation Team (FFQCM).
2.10.5. Aeromedical Evacuation Communications Team (FFQCR). Provides
communications capability to any AE UTC when mission requirements dictate, and other
forms of communications are considered unavailable. Deploys from home station with
communications security for secure communications capability. AE communications
equipment is organic to AE equipment UTCs and is not a stand-alone communications UTC.
2.11. Force Protection.
2.11.1. Civil Engineering (CE) has the primary responsibility to provide facility hardening
for the staging/AES facility and ancillary structures associated with it (e.g., logistics storage,
laundry, latrines, anti-hijacking areas, patient leisure areas).
2.11.2. In accordance with AFH 10-222V1, Civil Engineer Bare Base Development; AFH
10-222V10, Civil Engineer Camouflage, Concealment, and Deception Measures and AFH
10-222V14, Civil Engineering Guide To Fighting Positions, Shelters, Obstacles And
Revetments. CE provides hardening for AE and ERPS. In the event CE does not provide
support, staging/AE personnel harden (e.g., sandbag) their own facilities.
2.11.3. The senior officer of ERPS or AE establishes weapons plans, policies, procedures,
and processes upon arrival. Weapons are defined as any device which may be used to inflict
injury or death, to include, but not limited to, firearms, explosives, ammunition, knives
(including multi-purpose tools), etc. Weapons handling and storage procedures include:
2.11.3.1. Ensuring the proper control of weapons when temporarily stored in the facility.
2.11.3.2. Outlining the proper storage and distribution procedures for weapons that are
ERPS/AE assets. Establish a secure site for ERPS/AE defensive weapons and
ammunition.
2.11.3.3. Establishing clear policies defining personnel authorized to carry weapons:
Members of security forces or Military Police performing official duties are authorized to
carry a firearm while in the ERPS/AE facility. The ERPS/AE senior officer or Wing/CC
may issue written authorization to other individuals with specific mission requirements to
carry weapons into the ERPS/AES in accordance with the Laws of Armed Conflict, the
Geneva Conventions, and AFI 31-117, Arming and Use of Force by Air Force Personnel.
2.11.3.4. Determining and establishing a secure weapons storage area and activity log.
Ensure persons unauthorized to carry firearms or other weapons in the ERPS/AES facility
are identified and disarmed.
2.11.3.5. Positioning of the clearing barrel. Refer to AFMAN 31-129, USAF Small Arms
and Light Weapons Handling Procedures.
2.11.3.6. Weapons are identified and inventoried using AF Form 1297, Temporary Issue
Receipt.
2.11.3.7. Establishing and managing the disposal of collected weapons and ammunition
with security forces and/or armory.
2.11.4. Temporary storing of weapons for redeploying staging/AE personnel includes:
2.11.4.1. Securing and reclaiming weapons to and from security forces.
2.11.4.2. Securing weapons in approved travel case or storage area.
2.11.5. Patient Staging and AE personnel may be tasked with post-attack reconnaissance
under the direction of explosive ordnance disposal.
2.11.6. Policy and guidance for entry control points are established to include entry, exit and
firearm management. Entry control point policy include; personnel identification, passwords,
and protective barriers.
Chapter 3
REQUESTING AE PATIENT MOVEMENT THROUGH PMRC
3.1. Patient Movement Considerations. Weather, maintenance problems, availability of

aircraft, crew duty day limitations, en route stops, and diversions may cause delays,
cancellations, or denials to requests for AE patient movement. Secondarily, patients should not
experience any degradation in the delivery of a required level of care as a patient moves through
different phases of patient movement, e.g., ground to air to ground.
3.1.1. The flight surgeon and/or the referring privileged provider, in conjunction with the
PMRC works to mitigate any issues resulting from degradation in the level of care. An
accepting privileged provider and available bed is verified for all non-contingency patients
prior to PMR submission.
3.1.2. If a non-contingency inpatient is transiting a Continental United States (CONUS)
patient staging facility without the required clinical capability, an interim RON accepting
privileged provider at a local hospital will be arranged by the referring privileged provider
and documented in the PMR. (T-0). Note: The PMRC provides guidance in situations when
contingency patients also require an accepting privileged provider.
3.2. Requesting AE for Patients. The referring privileged provider assesses risks associated
with patient movement and determines the need for evacuation. The requesting provider obtains
an accepting provider at the receiving facility. The in-flight environment and the physiological
stresses of flight described in Chapter 7 can impair the ability to assess and deliver care while
airborne. The referring privileged provider consults the governing PMRC to consider standards
for aeromedical movement of patients, flight safety and operational constraints of the current
operational environment. Consultation between the referring privileged provider and the PMRC
is essential to mitigating these risks. Transport can be executed by USAF and or contracted
aircraft. The request for PM begins with the initiation of a PMR by the referring privileged
provider. Patient eligibility for movement is in accordance with DoDI 6000.11.
3.2.1. PMRs and AF Form 3899s, Aeromedical Evaluation Patient Record, are generated at
the referring MTF by entering patient information into TRAC2ES. The AF Form 3899 has
the referring privileged provider’s signature and orders for AE (ground transport, staging, in-
flight, and remain-overnight phases). The AF Form 3899 is the authorizing document for in-
flight care, as well as part of the patient’s permanent medical record.
3.2.2. Referring Privileged Provider. The referring privileged provider initiates a medical
referral and clinical assessment, much like they do when requesting medical consultation.
The VFS reviews this information, makes adjustments and interventions, then oversees the
movement of the patient from one location to the next. Both providers have significant
clinical input into the patients' care and outcome.
3.2.2.1. The referring privileged provider is responsible for finding an accepting
privileged provider at the destination facility, if applicable. The PMRC verifies an
accepting privileged provider, once obtained by referring privileged provider.
3.2.2.2. The referring privileged provider stabilizes patients entering the regulated
patient movement system as much as the situation and resources allowed include, but are
not limited to securing airway, controlling hemorrhage(s), treating shock and stabilizing
fractures.
3.2.2.3. The referring privileged provider is responsible for completing transfer orders on
the AF Form 3899 for all URGENT (“U”), PRIORITY (“P”) and ROUTINE (“R”)
patients.
3.2.2.3.1. This order includes the phone number, service, and name of the accepting
provider (e.g., Transfer to Dr. X, General Surgery) as applicable.
3.2.2.3.2. Hand-written orders and patient information are required to be written
legibly so accurate patient information is relayed.
3.2.2.3.3. After consulting with the governing PMRC and the VFS, the referring
privileged provider consider the adverse effects of stresses of flight when writing
orders.
3.2.2.3.4. The referring privileged provider signs all orders for AE.
3.2.2.3.5. All special diets are ordered by the referring privileged provider and
documented on the EHR or AF Form 3899.
3.2.2.3.6. The referring privileged provider is responsible for writing or dictating a
transfer summary whenever a patient is being transported in the AE system.
3.2.2.3.7. The referring privileged provider provides key information, including
pending labs, x-rays, consults and the status of the patient and their anticipated needs.
3.2.2.3.8. The referring privileged provider outlines recurring assessment
requirements.
3.2.2.3.9. The referring privileged provider in collaboration with the VFS orders any
O2 requirements needed during flight.
3.2.2.3.10. The referring privileged provider in collaboration with the VFS provides
appropriate documentation requesting use of Vacuum Spine Board (VSB) or a NATO
litter with a cervical collar and may have an ERCC team assigned to the patient.
3.2.2.3.11. The referring privileged provider always uses a cervical collar (C-Collar),
in conjunction with the VSB, if C-Spine injury is suspected.
3.2.2.3.12. The referring privileged provider will include the burn criteria as defined
by American Burn Association (ABA) (http://www.ameriburn.org) described in
Attachment 10 and will follow Chapter 8 for prompt consultation with a burn
surgeon and transport to a burn center. (T-0).
3.3. Local Flight Surgeon. The flight surgeon is the local authority for determining whether
patients are physiologically ready for air transport. The flight surgeon or privileged provider in
consultation with the VFS, clears AE patients for flight. The flight surgeon in collaboration with
the VFS, may also determine if a patient’s category should change and adjust AE clinical care as
indicated to safely transport patient.
3.3.1. Patients in RON status remain under the care of the local FS, unless transferred to
other privileged providers for specialty or higher-level care.
3.3.2. The flight surgeon reevaluates each RON patient for continuation in the AE system,
including those that are transferred. This clearance to fly (proceed) is documented on the
EHR or AF Form 3899.
3.3.3. If transferred, the local MTF flight surgeon assesses whether the patient’s condition
warrants removal from AE until further stabilized for movement.
3.3.4. When no FS is available, the privileged provider, identified by the commander, at the
RON location is responsible for the RON patients and is responsible for the above duties.
Approval for the RON with no FS is confirmed with the PMRC before the patient departs the
sending facility.
3.4. Submitting a PMR for Validation and Movement.
3.4.1. Submit a PMR as soon as the need for movement is determined. The patient
movement process begins when the referring MTF electronically submits the PMR to the
PMRC through TRAC2ES. If the MTF does not have access to TRAC2ES, call the PMRC
for assistance in obtaining access and/or submitting the PMR. The PMR contains fields for
clinical data and administrative data.
3.4.2. The PMR accurately reflects the patient’s current condition and medical
equipment/durable supply requirements. The PMR also provides a succinct care summary to
ensure the receiving MTF is prepared and capable for assuming care of the patient upon
arrival. Significant changes in the patient’s condition require updates to the PMR. Submitting
thorough clinical and administrative information shortens the validation process. The PMR
content contains the following information (reference Table 3.1) and is consistent with
documentation contained within the patient’s medical record.
3.4.3. For ROUTINE Precedence moves, if patient is going to a civilian facility, a TRICARE
Authorization number is needed for care prior to PMR validation. Additionally, if patient is
moved by civilian ambulance on either end of the move, a TRICARE authorization number
for ground transportation is needed prior to PMR validation. For URGENT or PRIORITY
moves, authorizations can be acquired at a later time.
3.4.4. Required information and documentation (e.g., scanned copies of passports, contractor
letters of authorization) vary by patient situation and theater of operation. Contact your
servicing PMRC for detailed guidance.
Table 3.1. Minimum Requirements to Enter a Patient Movement Request.

Information Notes
Diagnosis
Reason for Movement
Concise and accurate Include any procedures/treatments specifically
medical history addressed in this document, related to patient
diagnosis (e.g., chest X-ray results at least 24 hours
post chest tube removal).
Date and time of last Absolute dates and times are used (e.g., 3 Aug 14);
relevant surgery not relative dates/times (e.g., 3 days ago).
Privileged provider’s
orders
Plan of care
Current Vital Signs Vitals are documented in the PMR within 72 hours
(VS) prior to validation for all routine in-patients. All
URGENT (U) and PRIORITY (P) patients VS are
documented in the PMR within 12 hours prior to
validation.
Significant lab values Current hemoglobin and hematocrit (H&H) for all
trauma, post-arrests, and post-operative patients. If
ventilated, arterial blood gas results within 12 hours
of validation are documented.
Oxygen (O2) A pulse oximeter is available on board AE aircraft,
requirements but referring privileged providers are required to
recognize these devices can give erroneously higher
readings under certain physiologic conditions (e.g.,
carbon monoxide poisoning, dehydration, anemia,
impaired peripheral circulation, and high or low
cardiac output states). Note: A cabin altitude
restriction is sometimes required in addition to
supplemental oxygen therapy.
Documentation for Infusion documentation includes the medication,
regional and epidural dosage, drug concentration, location, rate of
pain management infusion, pump type, and the service that is
infusions overseeing the infusion. Document pain score.
Include pain medication for break-through pain.
Notification to the VFS of any infusion line is
required prior to clearing the patient for flight.
Be aware of the action and side effects of patient
specific medications prior to starting care and prior
to departure.
During the placement of the epidural catheter if
“loss of resistance technique with air” has been
used, or a “wet tap” occurs, the patient is held a
minimum of 24 hours prior to planned AE mission
to decrease the possibility of complications.
All current medications A physician orders and/or reviews all pain
with dose, frequency, medication loading dose(s), PCA bolus dose
and route amount, lock-out interval, basal flow (continuous)
rate, breakthrough pain orders, continuous
peripheral IV infusion or saline lock, and over-
sedation protocol on the EHR or AF Form 3899.
Self-medicating Confirm the self-administering medication (SAM)
patients is clearly indicated in the orders and the “SAM”
box is marked on the EHR or AF Form 3899.
Nutritional status/diet
orders
Ambulatory status
and/or physical
limitations
Travel limitations Stops, RONs, cabin altitude restriction.
Patient equipment External fixators, epidural pain pumps, cardiac
monitors, chest tube drainage systems, pulse
oximeters, wheelchair to include dimensions,
crutches.
Request for MA or When patient needs exceed the capabilities of the
NMA or specialty aeromedical evacuation crew or NMA. A complete
medical teams discussion of NMAs & MAs can be found in
paragraph 6.5.
3.5. Determining Movement Precedence.
3.5.1. Precedence determines how quickly the patient is moved by the patient movement
system. Precedence is determined by the clinical requirement for saving life, limb, or
eyesight and is consistent with the delivery date to the destination medical facility. The
movement precedence is determined through consultation between the referring and
accepting privileged provider. The VFS and the PMRC make the final determination on the
precedence. Note: During contingency operations, additional information may be required as
determined by the PMRC. Generally, patients may be regulated to the closest uniformed
services treatment facility having the medical capability to care for the patient.
3.5.2. Precedence categories are URGENT (“U”), PRIORITY (“P”) and ROUTINE (“R”).
All “U” or “P” requests are approved in accordance with PMRC guidelines.
3.5.2.1. If a request for “U” or “P” movement is not validated and the referring
privileged provider does not concur with the decisions, he/she can request a review by
TCSG, the appropriate theater command surgeon, or designated representative.
3.5.2.2. Report “U” and “P” patients directly to the PMRC with the help of the AE clerk
or patient administration personnel. “U” or “P” patients require direct communication
between the referring, accepting privileged providers and VFS.
3.5.2.3. “U” Precedence (stabilizing vs unstable) requires immediate PM to save life,
limb, eyesight, or prevent serious complications of injury or existing medical condition.
Immediate action is taken to obtain suitable transportation to meet patient requirements.
Timeline for movement is as soon as possible and validated by supporting PMRC VFS.
3.5.2.4. “P” Precedence (stabilizing vs stabilized) requires expedient PM and prompt
medical intervention when care is unavailable locally and medical condition could
deteriorate; PM is required sooner than the next scheduled channel AE mission. Timeline
for movement is defined by the competent medical authority and validated by the
supporting PMRC VFS.
3.5.2.5. “R” Precedence (stabilized vs stable) requires timely PM, can tolerate longer
periods except when clinical requirements/or status change warrants higher movement
precedence. Timeline for movement is defined by competent medical authority and
validated by the supporting PMRC VFS.
3.5.2.6. Response Time.

3.5.2.6.1. Many factors influence response time for “U” and “P” movements.
Validation of the PMR by the PMRC is required before airlift is allocated. The
PMRC provides the validated PMR to the appropriate C2 agency to procure airlift.
3.5.2.6.2. The 618 Air and Space Operations Center/AMD/AECT considers all airlift
sources to include commercial air ambulances. The PMRC considers alternative
sources of patient movement or transport if airlift response time does not meet the
patient’s clinical needs.
3.6. Special Category Patients.
3.6.1. Special patients can be designated by the AECM, Patient Movement Clinical
Coordinators (PMCCs), VFS or responsible physician and are coordinated through the
PMRC.
3.6.2. Indicate a patient is a special category patient in the TRAC2ES PMR if the patient is
of command interest, any patient O-6 or higher (active or retired), E-9 depending on position
(command), foreign national, secretarial designee, or any other high visibility patient
movement.
3.7. Determining Patient Classification.
3.7.1. Classification are assigned by a referring privileged provider in coordination with the
PMRC and designates the patient status, based on diagnosis and ability to self-help in an
emergency. The AECM may assign a higher (upgrade) classification, e.g., 2B to 2A if the
patient’s condition warrants.
3.7.1.1. A patient’s classification will not be downgraded without the approval of the
VFS (e.g., 1A to 1C). (T-0). Patient status changes can and do occur after the initial
reporting of patient movement requests. All medical personnel are required to
continuously re-assess and document patient status changes and ensure updated
information is communicated to the PMRC.
3.7.1.2. The AECM notifies C2 who then contacts the governing PMRC of any change
in patient status or classification as soon as possible. Complete DD Form 2852, Patient
Movement Event/Near Miss Report or Joint Patient Safety Reporting (JPSR) worksheet,
and update AF Form 3829, Summary of Patients Evacuated by Air. The DD Form
2852/JPSR Worksheet is protected from disclosure under Department of Defense
Instruction 6025.18, Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule Compliance in DoD Health Care Programs; and DoDI 6025.13, Medical
Quality Assurance (MQA) and Clinical Quality Management in the Military Health
System.
3.7.2. Patient classifications (reference Table 3.2).
3.7.2.1. Patients are classified according to the severity of symptoms.
3.7.2.2. 1A and 1B patients will have standing and/or as needed (PRN) medication
orders for agitation/anxiety/sleep. (T-0).
3.7.2.3. 1A – Severe. Psychiatric litter inpatient requiring the use of restraining
apparatus, sedation, close monitoring and are required to have a MA.
3.7.2.3.1. Patients who require restraints have them applied prior to boarding the
aircraft, are sedated for flight, and require close monitoring.
3.7.2.3.2. Restraints are four-point restraints. Patients are continually monitored
throughout the flight with line of sight at all times while in the AE system. Monitor
the respiratory status of sedated patients (to include pulse oximeter) at regular
intervals and observe for signs of over-sedation.
3.7.2.3.3. The referring physician, PMRC, MA, or AECM may determine the
patient’s behavior is too high risk to flight safety, thus requiring further stabilization.
3.7.2.3.4. The patient is stabilized prior to AE movement with appropriate
psychiatric medications that effectively control symptoms of extreme agitation and/or
anxiety.
3.7.2.3.5. If the patient requires an MA, the MA is the same gender, preferably of
equal or higher rank if operationally feasible.
3.7.2.3.6. Patients only RON at a bedded MTF.
3.7.2.3.7. Patients travel in hospital garments, pajamas, or physical training (PT)
gear. All strings, laces, and belts are removed from the PT gear.
3.7.2.4. 1B – Intermediate. Psychiatric litter inpatient of intermediate severity.
3.7.2.4.1. Patients should be transported on a litter. In coordination with the AECM,
these patients may be allowed to sit up for comfort under close observation.
3.7.2.4.2. Psychiatric patients may require tranquilizing or sedating medications to
prevent harm to self, aircrew members, or the aircraft. These patients require a
restraint order for applying restraints or have restraints immediately available at the
litter. Once available restraints are applied to the patient, the AECM contacts the VFS
for an applied restraint order.
3.7.2.4.3. Do not seat near exits, flight deck or where emergency equipment (e.g.,
oxygen, crash axes, or emergency O2 shut off valve) is kept. Note: Inform all
aircrew members of the patient’s location.
3.7.2.4.4. Patients should travel in hospital garments, pajamas, or physical training
(PT) gear. All strings, laces, and belts are removed from the PT gear.
3.7.2.5. 1C – Ambulatory psychiatric inpatient of moderate severity and may require an
attendant for movement.
3.7.2.5.1. May be dressed in civilian or military clothing.
3.7.2.5.2. Do not seat near exits, flight deck or where emergency equipment (e.g.,
oxygen, crash axes, or emergency O2 shut off valve) is kept.
3.7.2.5.3. Patients do not self-medicate or carry their own medication.
3.7.2.6. 3C - Inpatient ambulatory, drug, or alcohol (substance) abuse patient going for
inpatient treatment.
3.7.2.6.1. Individuals who have recent drug or alcohol consumption may exhibit
signs or symptoms of withdrawal (reference paragraph 8.20.13).
3.7.2.6.2. Patient may sit next to exits and O2 shut off valves, if determined to be
competent by a FN.
3.7.2.6.3. Patients may RON at an ERPS if determined by the FS and the senior
nurse at the ERPS to be stable and safe.
3.7.2.7. 5B - Outpatient ambulatory, drug, or alcohol (substance) abuse, going for
treatment. Note: Patients may RON at an ERPS if determined by the FS and senior nurse
at the ERPS to be stable and safe.
3.7.2.8. 5C - Psychiatric outpatient going for treatment or evaluation. Note: Patients
may RON at an ERPS if determined by the FS and senior nurse at the ERPS to be stable
and safe.
Table 3.2. Patient Classification.

CLASS 1 Neuropsychiatric Patients
1A Severe Psychiatric Litter Patients. Psychiatric patient requiring the use of
a restraining apparatus, sedation, and close supervision at all times
(reference paragraph 3.7.2.3.).
1B Psychiatric Litter Patients of Intermediate Severity. Psychiatric patients
may require tranquilizing or sedating medications to prevent harm to
self, aircrew members, or the aircraft. These patients have a restraint
order for applied restraints or restraints immediately available at the
litter.
Once available restraints are applied to the patient, the AECM contacts
the validating flight surgeon for an applied restraint order (reference
paragraph 3.7.2.4.).
1C Psychiatric Ambulatory Patients of Moderate Severity. Psychiatric
patients who are cooperative and who have proved reliable under
observation. May or may not require an attendant for movement
(reference paragraph 3.7.2.5.).
CLASS 2 Inpatient Litter Patients (Other than Psych)
2A Immobile Litter Patients. Patients unable to move about on their own
volition under any circumstances and requires assistance with egress.
2B Mobile Litter Patients. Patients able to move about on their own volition
in an emergency. Able to sit in a seat if desired.
CLASS 3 Inpatient Ambulatory Patients (Other than Psych)
3A Ambulatory patients, non-psychiatric and non-substance abuse, going for
treatment or evaluation, requiring care en route.
3B Recovered ambulatory patient returning to home station.
3C Ambulatory, drug, or alcohol (substance) abuse, going for inpatient
treatment.
CLASS 4 Infant Category
4A Infant under 3 years. of age, occupying an aircraft seat, going for
treatment.
4B Infant under 3 years. of age, occupying a seat and returning from

treatment.
4C Infant requiring an approved air worthy incubator.
4D Infant under 3 years of age, occupying a litter.
4E Outpatient under 3 years of age.
CLASS 5 Outpatient Category
5A Ambulatory outpatient, non-psychiatric, non-substance abuse, going for
treatment.
5B Ambulatory outpatient, drug, or alcohol (substance) abuse, going for
treatment (reference paragraph 3.7.2.7.).
5C Psychiatric outpatient going for treatment (reference paragraph
3.7.2.8.).
5D Outpatient on litter for comfort, going for treatment.
5E Returning outpatient, on litter for comfort.
5F Returning outpatient, returning to duty.
CLASS 6 Attendant Category
6A MA: Physician/Nurse/Tech required for specific medical needs based
on the patient's condition and treatments required in flight.
6B NMA: family/unit member for the purpose of providing assistance on an
AE mission in accordance with DoDI 6000.11 (reference paragraph
6.5.).
3.8. PMR Validation and Acceptance for Flight.
3.8.1. When the PMR is submitted with required information and all approvals are
completed, a PMCC or VFS clinically validates, as appropriate. The Patient Movement
Operations Officer (PMOO) administratively validates the PMR. The airlift C2 agency, after
receiving a validated PMR, selects the most advantageous mission for the patient and notifies
the PMRC of the mission, who then notifies the facilities and ground transportation agencies.
The Patient Movement Operations Officer (PMOO) builds the mission in TRAC2ES as
required and the Duty Controllers makes appropriate notifications to originating and
destination facilities prior to the mission and during execution.
3.8.1.1. If the patient requires total care or continuous observation, a MA from the
originating medical facility or staging unit may be required to accompany the patient.
3.8.1.2. The PMRC coordinates any requirement for a specialty team or MA made by the
referring privileged provider, in coordination with the VFS.
3.8.2. The validation process includes confirming the patient is medically cleared for flight
and this movement is appropriate when all circumstances are considered. Circumstances
include, but are not limited to information identified in paragraph 3.5 as well as:
3.8.2.1. Availability of adequate care in the local economy.
3.8.2.2. Patient transportation eligibility. Found in DoD 4515.13R Air Transportation
Eligibility and DoDI 6000.11.
3.9. Patient Movement Operations.
3.9.1. There are Three TPMRCs (USTRANSCOM Patient Movement Requirements
Centers). They are joint Units reporting directly to the TCSG and serve as DoD's manager for
the development of policy and standardization of procedures and information support
systems for global patient movement. TPMRC-Americas covers North and South America
and includes Alaska. TPMRC-East covers EUCOM, CENTCOM and AFRICOM theaters,
and TPMRC-West covers INDOPACOM. The TPMRCs implement policy and
standardization for the regulation, clinical standards, and safe movement of uniformed
services and other authorized, or designated patients. They also orchestrate and maintain
"global oversight" in coordination with the geographic combatant commanders and external
intergovernmental organizations, as required and in accordance with USTRANSCOM
guidance.
3.9.2. TPMRC-A. Located at Scott Air Force Base, IL and is responsible for patient
movement within U.S. Northern Command (USNORTHCOM), from U.S. Southern
Command (USSOUTHCOM), and from USNORTHCOM. TPMRC-A coordinates with
Outside the Continental United States (OCONUS) CCMDs to receive PM inbound to
USNORTHCOM. Contact Information: DSN: (312) 779-4200, commercial: (618) 229-4200;
toll free: 1-800-303-9301.
3.9.3. TPMRC-E. Located at Ramstein AB, Germany, and is responsible for patient
movement within and from USEUCOM, USAFRICOM, and United States Central
Command (USCENTCOM) (when there is no JPMRC). Contact Information: DSN: (314)
480-8040/2264 or Civilian: 0049-6371-47-8040/2264.
3.9.4. TPMRC-W. Located at Joint Base Pearl Harbor-Hickam and is responsible for patient
movement within and from United States Pacific Command (INDOPACOM). Contact
information: DSN: (315) 448-1602/04/09 or commercial: (808) 448-1602/04/09.
3.10. Validating Flight Surgeon (VFS).
3.10.1. The VFS is assigned to each PMRC and provides medical direction during transport
for all patient types served by the PM system.
3.10.1.1. The VFS seeks prompt specialty or subspecialty consultation, as appropriate,
when a patient’s needs exceed their scope of practice. The VFS, working in concert with
the PMRC PMCCs, identifies skill requirements to ensure appropriate level of care
required for any patient movement. The VFS also assesses any infectious disease risk to
decrease risk to other patients and crew members.
3.10.1.2. The VFS works with the referring and accepting privileged providers, as well
as any ERCC team MA when planning and coordinating the patient’s transfer. If there is
a question as to the level of care required, the VFS works with the sending physician and
ERCC team MA to make a determination.
3.10.2. The VFS ensures compliance with applicable accepted practice standards for air and
ground patient movement.
3.10.3. Medical direction is transferred from the VFS to a privileged provider traveling with
AE patients as a MA, an ERCC team physician or other specialty team.
3.10.4. AECMs transporting AE patients provide care in-flight under the medical direction
of the VFS.
3.10.5. If the VFS and/or PMRC have a question regarding the AECMs’ ability to care for a
patient without a specialty care team or MA, the VFS and/or the PMRC contacts the CNE at
the AES tasked with the mission to determine appropriate staffing levels for the mission.
3.11. TRAC2ES.
3.11.1. TRAC2ES is the Automated Information System supporting patient movement
which links the originating and destination MTFs with medical transportation assets and C2
infrastructure to plan and manage PM, and to maintain continuous global awareness of the
PM system. The user interface is an exclusively web-based application (T-Web), but a
computer-based spreadsheet called a TRAC2ES unloadable Contingency Spreadsheet
(TUCS) exists for users with sporadic or non-existent internet connectivity. The system is
used by: PMRCs, fixed and deployed MTFs, PM C2 elements, and the headquarters of Joint
Task Forces, combined task forces, and CCDRs. For the latest information regarding
TRAC2ES, go to https://trac2es.transport.mil or email trac2es@us.transcom.mil. Users
may apply for new accounts by contacting the TRAC2ES Helpdesk at:
transcom.scott.tcj6.mbx.service-desk@mail.mil. The help desk can provide forms and
assist with guidance to register for a new account.
3.11.2. Refer to USTRANSCOM guidance for additional information.
Chapter 4
ORIGINATING AND DESTINATION FACILITY
4.1. General Information. Originating and destination facilities assume the responsibilities of
patient staging in the absence of an ERPS. It is the responsibility of the originating facility to
identify, create and submit a PMR and identify PMI, supplies and medications required to
monitor and treat the patient throughout the AE system. MTF/CC coordinates with supporting
patient staging facilities for PM operations requirements and procedures. AECMs are responsible
to review the PMR to ascertain if the AE system is required to bring PMI with the mission
(reference chapter 5 for additional ERPS information and chapter 6 for patient preparation).
4.2. MTFs and ERPS responsibilities.
4.2.1. Monitor TRAC2ES daily to identify any inbound/outbound patients regulated to their
facility.
4.2.2. Verify information on the mission manifest, including patient information, load data,
special equipment requirements, meals, and AE mission information with appropriate
agencies.
4.2.3. Update ITV events, and document in TRAC2ES, to assist with patient tracking and
clinical updates.
4.2.4. Coordinate patient and mission changes with appropriate PMRC and C2 agencies.
4.2.5. If clinical/mission status changes occur, the MTF/ERPS provides an up-to-date copy
of the PMRs and TRAC2ES mission manifest to the AE crew upon patient delivery.
4.3. Theater Medical Data Store. TMDS is a theater specific data repository for clinicians to
gain patient’s medical information. Medical records collected from Theater Medical Information
Program - Joint (TMIP-J) applications flow into the databases and are accessible worldwide
through TMDS.
4.4. Travel Authorizations. The originating facility provides a valid, funded travel order for all
US Armed Forces and non-US Armed Forces patients and attendants (revenue reimbursable/pay
patients).
4.4.1. Prepare the travel order or transportation authorization:
4.4.1.1. Include a complete billing address for non-US Armed Forces patients.
4.4.1.2. Attach the “Secretarial Designee” letter (if applicable) authorizing AE and
specifying the reimbursable rate.
4.4.1.3. Send a copy of the travel order to the TCSG within five workdays after the
patient leaves the facility to:
Table 4.1. TCSG.

TCSG
Third Party Collections
510 POW/MIA Dr, Building P40-E
Room 217
Scott AFB, IL 62225

4.4.2. Prevent patient movement delay by authorizing alternate methods of transportation for
Armed Forces patients from the active component. Service policy/guidance directs the
members' understanding of the need for personal funds; amount limit, and means of payment
(e.g., Treasury checks, money order, and cash).
4.5. Transportation. In the absence of an ERPS, the originating facility are required to provide
appropriate patient preparation, transport, medical escort and manpower to safely load patients
and transfer the patients’ and attendants’ baggage, records, medical equipment, supplies,
medications, and valuables on and off the evacuation asset. The ERPS capability coordinates this
role if assigned/postured at the location.
4.5.1. Patients on approved litters are transferred and prepared according to patient
preparation requirements. The originating facility ensures patients have flight approved
equipment, appropriate clothing, and adequate levels of supplies, medications (reference
paragraph 8.22.5) and appropriate nutrition. Patients arrive a minimum of one hour prior to
scheduled take off (reference Chapter 6).
4.5.2. The originating and destination MTF/CC ensures the MTF has a process for:
4.5.2.1. Providing required MA to and from an evacuation asset.
4.5.2.2. Maintaining adequate communications with MTF personnel in case of an en
route emergency.
4.5.2.3. Planning and coordinating to preclude mission and patient delays on the flight
line.
4.5.3. MTF staff needs to plan for medication (e.g., pain, nausea, or anxiety) and oxygen
administration requirements during transport between the flight line and MTF. WARNING:
Maintain the level of clinical care throughout the duration of patient movement.
4.5.3.1. The MTF is responsible for providing an ACLS-credentialed staff to transport
patients to and from the aircraft and the medical facility when patient condition dictates.
If an ACLS-credentialed staff member is not available from the destination MTF, an
ACLS-credentialed AECM obtains/maintains custody and care of patient to the
destination MTF until appropriate transfer of care can be accomplished. The MTF
ensures the AECMs are returned to aircraft.
4.5.3.2. For a critical care patient, the ERCC team maintains custody and care of the
patient to and from the aircraft. The TPMRC or applicable C2 agency, coordinates the
ground transportation of the ERCC patient and team. The AEOT and ERPSS collaborates
with the TPMRC to ensure the ERCC team and equipment is recovered and returned to
either the AEOT or lodging as required.
4.6. Documentation and Transfer of Patient Records.
4.6.1. The EHR is the primary source for patient documentation. In the event the EHR is
unavailable, the AF Form 3899 series is utilized. If a patient arrives without EHR or an AF
Form 3899 and arrives with any other medical documentation information, those documents
are transcribed and attached onto an AF Form 3899 and become a permanent part of the
patient’s medical record.
4.6.2. The originating facility is responsible for patient documentation and transfer of
comprehensive patient information. Originating MTFs initiates applicable paperwork in
accordance with AFI 48-107V3; En Route Care Documentation, for the patients entering the
AE system. (e.g., AF Form 3899 series, baggage/anti-hijacking forms, baggage tags).
4.6.3. All facilities protects and securely transports medical information to and from the
evacuation asset in accordance with DoDM 6025.18, Implementation of the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs,
and DoDI 8580.02, Security of Individually Identifiable Health Information in DoDI Health
Care Programs. Note: The destination facility is responsible for assuring all patient
documentation is transferred and placed in the patient’s permanent medical record.
4.7. Mission Coordination. The MTF coordinates mission requirements with appropriate
personnel, such as patient census, launch and recovery times/staffing needs to include drivers or
vehicles, appropriate clinical points of contact at other MTFs and supporting agencies.
4.8. Accountability. All healthcare workers ensure patient accountability is maintained. This
can be maintained on Health Insurance Portability Accountability Act (HIPAA) compliant status
boards and log sheets. TRAC2ES PM Automated Information System may be used for ITV.
4.9. Entry Requirements. Sending facility/patient staging units ensures patients and attendants
meet passport, all visa, and immunization requirements of the country in which the receiving
facility is located. It also ensures patients possess a military, dependent, civilian or contractor
government identification (ID) card.
4.10. Patient Safety Events/Near Miss Events. The receiving facility ensures incidents or
significant changes in patient status that occur within 24 hours of patient arrival are reported on a
JPSR worksheet or DD Form 2852 (reference Chapter 9).
4.11. RON Patients. At a minimum, MTF commanders ensure their personnel complete the
following tasks for all RON patients at or near their facility:
4.11.1. Medically evaluate each patient upon arrival and daily, or as medical condition
requires.
4.11.2. Prepare patients both clinically (reference Chapter 6) and administratively for
further PM.
4.11.3. Provide safekeeping of patient valuables.
4.11.4. Ensure patients have proper nutrition, bathroom facilities, and a place to sleep/stay.
4.12. MTF Support Requirements for the Co-Located ERPS.
4.12.1. The MTF provides the supported staging facility with medical, mental health,
administrative, logistical, pharmaceutical, nutritional medicine, radiology, and other support
services as needed. Unless otherwise designated, the Chief of Aerospace Medicine has
oversight of clinical care functions.
4.12.2. The Chief of Medical Staff (SGH) at the MTF has a supporting responsibility for the
ERPS. The SGH is a Medical Corps officer who directly reports to the MTF/CC. The SGH is
responsible for oversight of clinical provider quality and scope of care; utilization of
professional resources; policies supporting medical care; and appropriate credentialing,
privileging, and peer review processes as outlined in AFI 44-119. If the ERPS is not co-
located with a MTF with a SGH available, a senior medical officer other than the
Commander is appointed for the above responsibilities.
4.12.3. Chief Nurse (SGN) at the MTF has a supporting responsibility for the ERPS. The
SGN is a Nurse Corps Developmental Team appointed senior nurse who reports directly to
the MTF/CC. The SGN has the authority and responsibility for the delivery of nursing
services. The SGN coordinates on all actions impacting nurses and maintains functional
control of Air Force nursing service personnel; officers, enlisted, civilian, and contractors.
The SGN plans, coordinates, and establishes practice and performance standards for all
nursing personnel, ensures enlisted nursing personnel practice within the scope and to the full
extent of their respective Career Field Education and Training Plan, and ensures peer review,
currency and competency for nursing service personnel. If the ERPS is not co-located with a
MTF with an SGN available, a senior nurse other than the commander is appointed for the
responsibilities.
4.12.4. The supporting MTF provides medical materiel support for patients transiting the
continuum of medical care. The MTF provides supplies, equipment, linen, medications, and
custodial services and the subsequent accounting for such materiel in accordance with
AFMAN 41-209, Medical Logistics Support.
4.12.5. The MTF Resource Management Office includes reports from the supported staging
facility as part of the MTF reporting requirements. The MTF assists the staging facility with
personnel, funding requests, requirements, and other services as needed.
4.12.6. The MTF supports network and terminal connectivity to TRAC2ES.
4.12.7. The MTF ensures the staging facility has enough physical space to accommodate
patient loads, infection control processes, readiness requirements and AE mission or
transportation surges.
4.12.8. The MTF Vehicle Control Officer (VCO)/Vehicle Control Non-Commissioned
Officer (VCNCO) provides appropriate vehicles for transportation needs and serves as the
liaison to the vehicle operations flight and the staging facility VCNCO.
4.12.9. The MTF provides Commander’s Support Staff services in support of disciplinary
actions, career training and leave monitoring.
4.12.10. The MTF provides personnel trained in patient loading as required.
4.12.11. Staging personnel provide nursing care for patients who have been transferred to
the ERPS awaiting transportation. Patients on life support systems or cardiac monitors, as
well as inpatient mental health patients are provided care in the adjacent MTF or local
community medical facilities, as appropriate. In the event additional care/support is required
for patients in the ERPS, the supporting MTF provides clinical/surgical interventions or other
ancillary care as required. All patients are assessed to ensure the ERPS is capable of
providing care as required.
4.12.12. Requirements to establish a patient staging facility include:
4.12.12.1. MTF Pharmacy support is available 24 hours/day either in-house or available
within one hour as deemed appropriate for scope of care by the MTF commander.
4.12.12.2. Radiology support (including: Magnetic resonance imaging, computerized

axial tomography scan and ultrasound) is available within one hour, 24 hours/day.
4.12.12.3. Mental health support is available within one hour, 24 hours/day. Mental
health support is prepared to respond and assess/treat patients as needed.
4.12.12.4. Surgical support (to including anesthesia) is available within two hours, 24
hours/day. Surgical consultants are available within one hour, 24 hours/day.
4.12.12.5. Nutritional medicine support for ERPS is available 24/7. Note: This is a
supporting MTF responsibility unless the staging facility has assigned nutritional
medicine personnel.
4.12.12.6. Immediate/in house access to advanced life support services 24 hours/day.
4.12.12.7. Intensive Care Unit (ICU) support and critical care specialist is available 24
hours/day at either the military or civilian MTF.
4.12.12.8. Emergency medicine support is available 24 hours/day.
4.12.12.9. Ambulance support is available within 20 minutes, 24 hours/day.
4.12.12.10. Staff physician support is available 24 hours/day.
4.12.12.11. Laboratory services are available within one hour, 24 hours/day.
Chapter 5
EN ROUTE PATIENT STAGING SYSTEM (ERPSS)
5.1. En Route Patient Stage (Facility).

5.1.1. The ERPSS facility is a key healthcare component of the AE system and provides
temporary holding capability for patients transiting the system. While some ERPSS are
located adjacent to a bedded facility, they are designed for short term complex medical-
surgical nursing care and limited emergent intervention. Critically ill patients receive care at
the nearest bedded MTF or by the CCATT while awaiting airlift. (T-1).
5.1.2. ERPSS facilities not co-located with a MTF need to identify their clinical capabilities
to support en route patients and develop mitigation plans to ensure appropriate clinical care
for patients which exceed the MTF/ERPSS capabilities. All staging facilities informs the
TCSG of any change to their Scope of Care by sending an email to:
transcom.scott.tcsg.mbx.tcsg-director@mail.mil.
5.2. Roles and Responsibilities.
5.2.1. Staging facility personnel:
5.2.1.1. Receive regulated/unregulated patients and provide continuing and supportive
medical care.
5.2.1.2. Prepare and “clear patients for flight” to ensure suitability for movement under
the guidance of the PMRC VFS (reference Chapter 6).
5.2.1.3. Brief patients and accomplish appropriate documentation and TRAC2ES inputs.
5.2.1.4. Provide ground transportation between the staging facility and the aircraft
according to flight line safety rules and regulations.
5.2.1.5. Provide facility security for the protection of assets, personnel, and entry control.
5.2.2. The ERPS Officer in Charge (OIC), if not established as a Commander on G-Series
orders through an OPORD or appointment by the supporting MTF, is the senior officer of the
team assembled regardless of AF Specialty Code (AFSC).
5.2.3. MTF/CC coordinates with supporting patient staging facilities for PM operations
requirements and procedures. The Medical Officer of the Day in the ERPS is responsible for
patient care oversight.
5.2.4. Flight Surgeon responsibilities:
5.2.4.1. The flight surgeon reviews the patient’s record, prescribed treatment, diet, and
address any current medical complaints upon arrival with appropriate documentation on
the patient’s EHR or AF Form 3899. The flight surgeon clears the patient for travel in the
AE system and coordinates status changes with the appropriate PMRC.
5.2.4.1.1. A flight surgeon evaluates and documents the patient's condition upon
arrival and every 24 hours.
5.2.4.1.2. The flight surgeon consults with medical specialists as needed and is
available on a 24-hr basis.
5.2.4.2. Makes rounds with the staging nurse at a minimum every 24 hours and updates
the EHR or AF Form 3899. In the event of a patient status change, report the change
through ERPS facility leadership and/or PMRC for updating TRAC2ES.
5.2.4.3. The TRAC2ES classification of inpatient or outpatient status is only one of the
initial data points used for determining the appropriate location for the patient to RON.
This is a clinical decision by the FS in collaboration with the PMRC validating authority.
The PMRC VFS may also be consulted for patients with complicated or unusual
conditions or any time further expertise is required or desirable.
5.2.5. A Patient Safety Manager (PSM) is appointed by the ERPS Senior Nurse and is
responsible for compliance with the policies (reference chapter 9).
5.2.6. The ERPS Administrator provides oversight to staging facility/ERPS Control Center
of personnel, logistics, biomedical equipment repair, facility manager, security,
transportation personnel and disaster response planning and coordination.
5.2.7. Pharmacy services are the responsibility of the supporting MTF unless pharmacy
personnel are assigned to the staging facility.
5.3. Vehicles.
5.3.1. The tasking agency (MEFPAK, MAJCOM, CCMD) tasks the appropriate vehicle
support, personnel, and equipment UTCs with the ERPS. Fixed staging facilities require
adequate Ambulance/Ambulance Bus (AMBUS) assets assigned to support PM
requirements.
5.3.2. The ERPSS-10 UTC deploys with two High Mobility Multipurpose Wheeled Vehicles
(HMMWV) packed out with Allowance Standard 904F medical equipment in accordance
with approved pack-out guidance. The ERPSS-10 is placed near the flight line to facilitate
loading/unloading patients from the aircraft.
5.3.3. The ERPS OIC appoints a VCO/VCNCO in writing. The VCO/VCNCO manages the
vehicles in accordance with AFI 24-301, Ground Transportation, AFI 24-302, Vehicle
Management, and local directives.
5.3.3.1. The VCO/VCNCO ensures appropriate personnel are trained to operate assigned
vehicles and verifies certification for flight line vehicle operations.
5.3.3.2. The VCO/VCNCO prepares and submits vehicle reports according to local
directives.
5.4. Interface with MTFs/Other Agencies.
5.4.1. The leadership element of the ERPS (OIC, Senior FS, Administrator and CNE):
5.4.1.1. Coordinate with the supporting MTF to establish administrative, ancillary
service, and clinical support requirements.
5.4.1.2. Establish communications with the appropriate PMRC.
5.4.1.3. Establish communications with all supported service tactical evacuation
assets/units.
5.4.1.4. Establish communications with all MTFs moving patients to the ERPS to ensure
transportation and continuity of patient care is maintained.
5.4.1.5. Establish communications with the base commander (deployed) and airfield
manager.
5.4.1.6. Establish communication with the AE C2 assets at the ERPS location. The ERPS
leadership team develops a relationship with the Air Terminal Operations Center, CE,
communications, transportation, dining facilities, flight safety, fire, and force protection
units. These units are notified of the presence of an ERPS facility on the base and the
mission support requirements inherent in the patient movement system.
5.4.1.7. The ERPS control center communicates any changes to the patient manifest or
patient condition directly with the ERPS OIC to ensure the most current medical
information is available to the AE crew.
5.5. Training.
5.5.1. AFI 41-106 is the governing AFI for ERPSS training, unit training, and deployment
requirements. The staging mission is a unique role integral to the successful movement of
patients. All personnel assigned to an ERPSS UTC attend the Aeromedical Evacuation and
Patient Staging Course. The AFTTP 3.42.57 has additional home station training
requirements.
5.5.2. UTCs pare and tailored to support expeditionary operations, require all personnel to
perform a variety of functions outside of traditional AFSC responsibilities. Standardized
training ensures mission success.
5.6. Expeditionary Medical Logistics.
5.6.1. The ERPSS utilizes WRM supply and equipment assets that may be pre-positioned.
Orders for medical materiel flow from the deployed unit through the MTF. The ERPSS-10
deploys with an initial seven-day supply and may use AF reachback support when a Theater
Lead Agent for Medical Materiel (TLAMM) is unavailable. The ERPSS-50 and ERPSS-100
deploys with a 30-day supply of expendable items. Orders for ERPSS-50 and ERPSS-100 are
passed to the supporting MTF or directly to the designated TLAMM.
5.6.2. Once the theater has sustained operations, the TLAMM system becomes the source for
all joint medical supply needs. ERPS is supported by the base MTF.
5.7. ERPS Facility Administration.
5.7.1. Maintain a comprehensive events log documenting activities, correspondence,
communications, and facility issues. The events log provides historical documentation of all
activities within the facility and can be used to verify activities, as well as actions taken by
unit personnel. All reports are submitted through the C2 chain.
5.7.2. Maintain a status board displaying appropriate information, such as mission, estimated
time of arrival, estimated time of departure, patient loads, and aircraft data.
5.7.3. Verify mission information including patient information, load data, special
equipment requirements and aircraft information with appropriate agencies as directed by
higher headquarters and local directives. Coordinate patient and mission changes with
appropriate PMRC and C2 agency to ensure airlift and crews are appropriate for mission.
5.7.4. Coordinate mission requirements with appropriate personnel, such as census, launch
and recovery times/staffing needs, to include drivers or vehicles, appropriate clinical points
of contact at other MTFs and supporting agencies.
5.7.5. Establish procedures to ensure the privileged provider physician at the originating
facility initiates appropriate documentation and signs the AF Form 3899, or AF approved
electronic patient documentation, recommending movement of patients and attendants. The
staging facility clinical staff, patient administration or medical regulating office provide
appropriate documentation to meet mission requirements, such as PMRs, patient manifest,
and patient baggage list. AF Form 3899, Standard Form 600 (SF 600), Chronological Record
of Medical Care or equivalent form, is available for ongoing documentation of patient care.
The flight surgeon clears the patient for movement and documents appropriately.
Additionally, the ERPS ensures processes are coordinated with local security forces to
store/dispose of weapons or ammunition which cannot be returned to the patient’s unit
liaison officer (LNO).
5.7.6. Ensure patient accountability is maintained at all times. Status boards or log sheets can
be used to maintain patient accountability provided they are compliant with HIPAA and
personnel are briefed on use, maintenance, and compliance issues.
5.7.7. Patient death in the ERPSS. If a patient death occurs in the ERPSS, the individual
remains are transported to the sending or host MTF with all records and appropriate
documentation, e.g., "Death Certificate”. If at an ERPSS-10, individual remains are to be
transported back to the providing user service facility.
5.8. Mission Launch and Recovery. Plans, policies, procedures, and processes are in place to
include the following:
5.8.1. Management, control, and training of MAs.
5.8.1.1. Stresses of flight.
5.8.1.2. Billeting and recall.
5.8.1.3. Attendant responsibilities relating to patient care.
5.8.1.4. Inventory and management of special equipment.
5.8.1.5. Delivery and recovery of patient to and from aircraft.
5.8.1.6. Documentation of patient treatments/therapies includes medication, special diet,
patient medical records, X-rays, SF 600, AF Form 3899, or equivalent form. This is the
responsibility of the MA to report to the AECM.
5.8.1.7. Proper handling of litters, NATO carriers and attire.
5.8.2. Management of administrative processes including:
5.8.2.1. Reviews of AF Form 3899 and TRAC2ES PMR.
5.8.2.2. Preparation of baggage list provided by TRAC2ES and DD Form 600, Patient’s
Baggage Tag.
5.8.2.3. Anti-hijacking process and presentation (reference paragraph 6.7).
5.8.2.4. Vehicle control including drivers, configuration of AMBUSs, ambulance or

opportune conveyance.
5.8.2.5. Flight line authorization, chocks, and approved communication devices.
5.8.2.6. Vehicle mechanical and security checks.
5.8.2.7. Flight line safety and security.
5.8.3. Management of all documentation including:
5.8.3.1. Providing AECMs notification of patient classification changes.
5.8.3.2. Completion of EHR or AF Form 3899.
5.8.3.3. Completion of AF Form 3838, Do Not Resuscitate (DNR) Certification for
Aeromedical Evacuation, if required.
5.8.4. Ensuring adequate medication supply for patient.
5.8.5. Briefing of patients scheduled for departure to include:
5.8.5.1. Potential for unscheduled overnight stops.
5.8.5.2. Possession of authorized/unauthorized articles.
5.8.5.3. Use of restrooms.
5.8.5.4. Hand-carried luggage, X-rays, medical records, and medications.
5.8.5.5. Sequence and order of patient loading.
5.8.5.6. Procedure and patient requirements during transport to aircraft.
5.9. Reports and Communication. All reports are submitted in accordance with AFMAN 10-
206, Operational Reporting (OPREP) and specific CCMD, Joint Task Force (JTF) and AFFOR
guidance.
5.9.1. Expeditionary (deployed) units report in accordance with C2 guidance e.g.,
(Component NAF CCMD, Joint Task Force, MAJCOM). In-garrison medical units report in
accordance with the Operations Event/Incident Report and AFI 41-106.
5.9.2. The Situation Report (SITREP) is completed by the deployed medical commander
(senior officer) to provide daily medical input for inclusion in the deployed wings’ SITREP.
Any ERPS may be required to provide information for this report (reference AFMAN 10-
206.
5.9.3. Intelligence reports, including medical intelligence, are forwarded through the medical
group.
5.9.4. Communications/Computer Systems Support. The ERPS-50 and 100 UTCs deploy
with radio equipment, organic to the equipment UTCs, to be operated by ERPSS personnel.
The CCMD defines the appropriate encryption capability for the current AF model and type.
Support for this radio system is required from base and/or expeditionary combat support
communication resources for initial setup as well as ongoing support for telephone, local area
network, and internet.
Chapter 6
PATIENT PREPARATION
6.1. Overview of patient preparation.

6.1.1. Patient preparation is critical to ensure continuity of care and safe transport. A
thorough review by the PMRC of patient condition and requirements is crucial. Coordinate
with the MTF FS or the VFS to ensure the patient is cleared for AE. Patient preparation is
completed by the sending facility and the staging personnel.
6.1.2. A hand-off tool assists in communication and serve as a checklist to assure correct
documentation paperwork, supplies, equipment, meals, and x-rays accompany the patient.
Obtain accepting physician name and contact information as required and arrange for any
specialized AE prior to PM (reference Attachment 6 and 8).
6.1.3. All patients are prepared; including but is not limited to providing proper medications,
equipment, supplies, briefings, and security measures. If a patient is improperly prepared for
flight, AECMs may not have time to address the issue with originating MTF or staging
facility prior to take off. On-the-spot ORM is accomplished and may include contacting the
local facility, VFS, or C2 as appropriate. Note: All patient preparation shortfalls are
documented and submitted on a JPSR worksheet or DD Form 2852. Inform C2 if equipment
is not available for flight to meet patient requirements.
6.2. Litters.
6.2.1. Litter patients and accompanying equipment will be delivered to the aircraft by the
sending facility on litters approved for flight. (T-1). The USAF AE system does not replace
litters and accompanying items in-turn.
6.2.2. Litters are prepared with:
6.2.2.1. Mattress.
6.2.2.2. Two blankets.
6.2.2.3. Two sheets.
6.2.2.4. One pillow and pillowcase.
6.2.2.5. Two litter straps.
6.2.2.6. Any additional items required for patient needs or weather.
6.2.2.7. During contingency operations, the minimum is a litter and two litter straps.
6.3. Clothing the Patient.
6.3.1. The originating MTF ensures litter patients who do not wear hospital pajamas wear
appropriate conservative seasonal attire and all patients require appropriate attire per patient
classification outlined in paragraph 3.7
6.3.2. These clothing requirements do not apply during field maneuvers, field exercises, or
other unusual circumstances.
6.4. Equipment and Supplies. Patient movement items. PMI remains with the patient to
destination MTF, whether it is an intra or inter theater transfer. Receiving facilities/ERPS are
responsible for ensuring PMIs continue with the patient for onward movement. Destination
facilities are responsible for recycling PMI back into the PMI system. Only AE approved
equipment is used. For non-standard/non-certified equipment, the sending facility begins the
waiver process according to AFMAN 11-2AEV3, and AFMAN 10-2909.
6.5. General considerations for attendants.
6.5.1. MA and NMA’s are regulated through the AE system to provide care or assistance to
the patient en route. They are not intended to be used to augment staff or perform attendant
duties at the destination facility. A competent medical authority may relieve attendants en
route upon approval of a VFS. Military service members acting as attendants are
expeditiously released upon arrival at the destination facility to return the capability to the
sending command as soon as possible.
6.5.2. The attendant is prohibited from having knives or weapons unless attendant is a guard
of a prisoner patient.
6.5.3. The attendant maintains line of sight with the patient at all times unless relieved by an
AECM/ERPS/MTF staff.
6.5.4. At the originating facility, all attendants are provided with a duty responsibility
handout along with verbal instructions (reference Attachments 3-5).
6.5.4.1. Recommend AECM carry copies of Attachments 3-5, in the mission package.
The AECM works closely with onboard MAs, special medical personnel/teams, NMA
and the aircraft commander to ensure the safety of all patients, passengers and crew in
addition to proper care for patients.
6.5.4.2. AE system is not responsible for returning attendants to their originating
location. Originating locations place attendants on orders to ensure return through the
passenger transportation system in in accordance with DoDI 4515.13R.
6.5.5. The attending physician may authorize one (or more if necessary) adult attendant. The
PMRC director is the approval authority. NMAs provide: moral/emotional support, assist
with activities of daily living, coordinate breaks with the AECM/Staging Facility/MTF Staff
and all other actions necessary for the patients’ health and welfare.
6.5.5.1. Military NMA, e.g., battle buddy (reference Attachment 5).
6.5.5.2. Family/non-military NMA (reference DoDI 4515.13-R; DoDI 6000.11; and
Attachment 3).
6.5.5.2.1. Additional family members may be authorized to accompany patient, as
exception to policy, when necessary to patient’s health and welfare after approval by
commander, MTF director, and concurrence of director of applicable PMRC.
6.5.5.2.2. If an immediate family member is not available, another adult may
accompany patient in NMA status on the determination of need and written
justification. NMAs are issued appropriate travel orders authorizing same category of
movement as patient.
6.5.5.2.3. Any family member not authorized travel, who chose to accompany the
patient is responsible for all costs associated with travel and lodging. Note: The
originating MTF clearly conveys this to the family and/or NMA prior to movement
and a document a statement of understanding in the PM.
6.5.6. MAs are required for patients whose needs exceed the capabilities of the medical crew
or who require special attention en route. The supporting PMRC identifies the requirement
for a MA that possesses the appropriate skill level and coordinates with the referring MTF.
The referring MTF will provide the required MAs, except during contingencies. (T-0). In
some instances, MAs may be additional AECMs with coordination of C2 and AES Chief
Nurse. A Physician MA may be called upon to consult on other patients. For MAs
responsibilities (reference Attachment 4).
6.5.6.1. Provide and coordinates patient care requirements with the AECM.
6.5.6.2. Familiarize themselves with the patient and serve as the clinical authority for
their patient’s care.
6.5.6.3. May, upon request, evaluate or help care for other patients on the AE flight as
needed.
6.5.6.4. Provide and document care including administering medications in-flight.
6.5.6.5. Remain with the patient and coordinate breaks with the medical crew.
6.5.6.6. At RON stops, MAs brief personnel providing direct patient care assigned to
their patient(s) during rest periods and remain available for consultations.
6.5.6.7. The MA either accompany the patient to the MTF or may be relieved by the
same level care provider from the receiving MTF at the flight line.
6.5.6.8. For all severe psychiatric patients (1A or 1B) requiring ongoing supervision, the
MA or NMA is the same gender and preferably of equal or higher rank if operationally
feasible.
6.5.6.9. Attendants who have completed their attendant duties may return to their
originating location as duty passengers through the normal duty passenger movement
process in accordance with DoDI 4515.13R.
6.6. Baggage.
6.6.1. Inform all patients and passengers regarding baggage restrictions and prohibitions, to
include the current Federal Aviation Administration (FAA) provisions on liquids, and the
general prohibition on bringing weapons and explosives onboard the aircraft.
6.6.2. Patients and passengers are authorized two pieces of checked baggage if space is
available on the aircraft or transport platform. Checked baggage may not exceed 62 linear
inches (length plus width plus height) or 70 pounds for each piece. Carry-on baggage fits
under the seat and may not exceed 45 linear inches. Any duffel bag, sea bag, B-4 bag, flyers
kit bag, or diver’s traveling bag that exceeds 62 linear inches but does not exceed 100 pounds
may be substituted for one of the checked baggage items. Note: This does not include A/B/C
bags or Individual Battle Attire Equipment. Every effort is made to keep this equipment with
the patient. If necessary, the A/B/C bags and excess gear may be moved as unaccompanied
baggage through travel management office (TMO) to home unit of record. For small aircraft
such as the C-21, bags are limited to one small bag not to exceed 30lbs.
6.6.3. Patient’s unit ships personal baggage in excess to the standard baggage allowance as
unaccompanied baggage in accordance with applicable service directives.
6.6.4. The MTF is required to:
6.6.4.1. Attach DD Form 600, Patient’s Baggage Tag, to each piece of patient baggage
to be stowed. Note: Baggage information is loaded and updated into TRAC2ES.
6.6.4.2. Deliver the TRAC2ES baggage manifest or AF Form 3851, Patient Baggage
Data, to the designated AE representative at the time of patient transport.
6.6.4.3. Place a copy of the temporary duty (TDY) travel order or travel authorization in
each piece of stowed and hand-carried baggage.
6.6.5. Hand-carried bags. The patient may bring a small hand-carried bag for personal items
for use during travel (including over-night stops). If a patient is self-medicating, the staging
facility or AECM ensures the patient’s medications are in his/her hand-carried baggage.
Hand-carried bags is labeled with the patient’s name and contact information but is not
tagged with a DD Form 600.
6.6.5.1. All baggage is screened and anti-hijacked, including carry-on bags (reference
paragraph 6.7).
6.6.5.2. Litter patient’s small bags may be secured on the litter with the patient with the
approval of the AECM.
6.6.5.3. Ambulatory patients or attendants carry-on baggage fit under the aircraft seat.
6.6.5.4. If a patient's baggage or valuables are lost and the MTF cannot determine
exactly where and how the loss occurred, the MTF or agency follows the chain of
custody, informs the appropriate C2 of the incident and includes enough information in
the inquiry to allow the C2 to trace the items. Exception: These procedures do not apply
to valuables the MTF/Originating facility has sent by registered mail.
6.6.6. Patient/attendants unaccompanied or untagged baggage is not transported onboard AE
aircraft. Unaccompanied or untagged baggage is transferred to Travel Management Office
(TMO) for disposition by the sending facility.
6.6.7. No show patients/attendants baggage is removed from the flight prior to departure.
6.7. Anti-hijacking.
6.7.1. Anti-hijacking procedures are conducted before departing for the flight line.
6.7.1.1. Conduct screening procedures in accordance with AFI 13-207-O, Preventing
and Resisting Aircraft Piracy (Hijacking), and FAA directives on all patients, MAs and
NMAs, and /or baggage. Prepare the certificate for the AECM with names of the
individuals searched and completion of anti-hijacking procedures. If a patient or attendant
refuses to comply with the requirements, do not transport this individual to the aircraft.
6.7.1.2. Patient identification is conducted during anti-hijacking procedures (reference
paragraph 6.9).
6.7.1.3. Inspect all hand-carried items.

6.7.1.4. Inspect patients and attendants either with a handheld or walk-through metal
detector, x-ray machine or by a physical check.
6.7.1.5. Identify any patient or attendant showing suspicious behavior.
6.7.1.6. Honor requests for visual/physical inspection instead of using x-ray or metal
detectors.
6.7.1.7. Conduct all screening procedures with the highest standard of military courtesy.
6.7.2. Follow OPORD during contingencies if Kevlar® helmet, flak vest and other
protective gear is needed while performing anti-hijacking procedures. When possible, anti-
hijacking is accomplished in an area away from the flight line.
6.7.3. Check each patient traveling to seek mental health treatment to ensure patient is not
carrying objects that could inflict harm to self or others, to include weapons in checked
luggage.
6.7.4. Use alternate anti-hijacking procedures for patients and passengers with implantable
cardiac pacemakers and defibrillators. WARNING: Electromagnetic interference from
handheld and stationary surveillance systems interferes with these medical devices. Changes
in pacing rates, shock, and possible cardiac arrest may occur.
6.7.5. Notify the appropriate DoD law enforcement agencies if suspicious items are found.
Unauthorized items are confiscated, returned to the unit LNO and documented on AF Form
1297. Unauthorized items in hand-carried luggage include firearms, ammunition, knives, etc.
Weapons and ammunition, whenever possible, are given to the patient’s unit LNO for storage
and/or return to home station, with appropriate documentation in the Events Log or on an AF
Form 1297. Firearms issued to individuals may be transported in checked luggage if declared
and if no ammunition accompanies the weapon. The pilot in command (PIC) is the final
authority for firearms on the aircraft.
6.7.6. Restrict inspected patients and attendants to a holding area. Re-screen individuals who
leave the holding area.
6.7.7. This statement is accomplished in accordance with AFI 13-207-O and documented on
the last page of the Patient Baggage Data (AF Form 3851): “Anti-Hijacking of all patients
and bags completed in accordance with AFI 13-207-O.” Followed by the printed name and
signature of person performing the check.
6.7.8. Escort guards for prisoner patients are military NMA, and the same policies and
procedures apply. An escort guard is required to ensure order and prisoner patient security
(reference AFMAN 11-2AEV3 and AFI 11-202V3, General Flight Rules, AMC Supp).
Guards accompany prisoner patients to their destination.
6.7.9. Classified materials held by official couriers are exempt from anti-hijacking
procedures.
6.8. Valuables.
6.8.1. Patients are encouraged not to carry valuables (e.g., large amounts of cash, checks,
and jewelry) while in the AE system.
6.8.2. The originating MTF conducts an inventory of all patient valuables:

6.8.2.1. For unconscious patients, the AF Form 1052, Envelope/Record for Patients
Storing Valuables, is used to inventory their valuables and personal items.
6.8.2.2. Coordinate with the next-of-kin, if available, to take valuables belonging to
unconscious or incompetent patients, who originate from military or other Government
hospitals, or send the valuables by registered mail to the patient's destination facility.
6.8.2.3. If the patient has more than $50 in cash, contact the Patient Administration
section for assistance.
6.8.2.4. The originating MTF provides a container for each patient's valuables. Place a
copy of their TDY orders in the bags and inside the container. The container is labeled
showing patient's full name, grade, cite number, service, and originating and destination
MTF.
6.8.3. The AECMs are not required to accept patient valuables unless the patient is
physically present for the flight.
6.8.4. The entire processing of valuables is witnessed and attested to by a disinterested
officer whenever possible.
6.9. Patient Identification.
6.9.1. All patients and attendants including active component, dependents, retirees, and
others require an identification (DoD identification card, passport, driver’s license, Common
Access Card), copy of their Travel Order (DD Form 1610, Request and Authorization for
TDY Travel of DoD Personnel or equivalent), and patients and attendants require an ID
wristband while in the AE system. Note: There may be times when patients/attendants arrive
to aircraft without ID bands (civilian transport, MASCAL, etc.), if this happens, the AECM
places an ID band on the patient.
6.9.1.1. The patient wristband includes patient’s last name, first name, TRAC2ES cite
number, date of birth, originating and destination MTF, rank, patient status and bar code.
All attendants, both medical and non-medical, excluding specialty teams, are listed above
the patient’s name.
6.9.1.2. All patients with allergies have a separate band listing out specific allergies
including medications, foods, and latex.
6.9.2. The attendant’s wristband includes the word “ATTENDANT”, TRAC2ES cite
number and the patient’s actual name. Specialty teams such as Critical Care Air Transport
Team (CCATT) as discussed in AFI 48-107V2, En Route Critical Care, are not required to
have an ID wristband.
6.10. Weapons.
6.10.1. Patients travel without weapons. Notify aircrew if authorized weapons are carried
onboard.
6.10.2. Weapons arriving at the aircraft with patients are cleared and returned to the patient's
unit or secured by the loadmaster and turned over to the appropriate agency at the destination
airfield.
6.11. Nutrition and meals. (reference AFI 48-116, Food Safety Program and AFMAN 44-144,
Nutritional Medicine).
6.11.1. Patient care guidelines.
6.11.1.1. Assess and document nutritional status (intake patterns, appetite, ability to
chew/swallow and digest), time of last meal, food allergies, and fluid intake.
6.11.1.2. Evaluate and document gastrointestinal (GI) status and/or symptoms, especially
for patients receiving pain medication and patients in the PM system for more than 24
hours.
6.11.1.3. Assist patients with preparation, positioning and eating, as necessary. If not
clinically contraindicated, elevate head or adjust them to an upright sitting position.
6.11.1.4. Check for food allergies, and verify diet order before administering patient
meals, snacks, and beverages.
6.11.1.5. Provide fluids at least every two hours for those not on fluid restrictions.
6.11.1.6. Administer meals and snacks as close to normal mealtimes as possible. Special
diets are served first. Times may be adjusted to the destination time zone if there are no
contraindications.
6.11.1.7. Time between the evening and breakfast meals will not exceed l5 hours. (T-3).
6.11.1.8. When operationally feasible, patients are fed prior to patient care hand-offs,
ground/aircraft departure and arrival, and if delay in feeding is anticipated due to
operational constraints.
6.11.1.9. Dietitians and/or diet therapy technicians may not be available to monitor all
aspects of dietetic/nutritional support and food safety. In this instance, local nursing
personnel, Public Health Officer (PHO), and/or flight surgeon to provide support,
oversight, and meals.
6.11.1.10. Notify the supporting C2 of significant impact/delays due to inadequate
dietetic support and/or food safety issues. Complete JPSR worksheet or DD Form 2852.
Provide detailed information on AF Form 3829, if indicated.
6.11.2. Packing meals.
6.11.2.1. Keep the entire meal as small as possible due to limited storage space aboard
the aircraft and other transportation assets.
6.11.2.2. Label the box containing the meal and snack with the following information;
name, diet, station enplaned, preparation date, and time.
6.11.2.3. Pack diabetic snacks separately, sealed in a bag. These may be placed in the
same box with the meal, however, clearly label these packages as snacks and indicate the
time for consumption.
6.11.3. Planning en route meal requirements (reference Table 6.1).
6.11.3.1. Patient diet information can be obtained from TRAC2ES by pulling a Mission
Manifest Report for the mission and then selecting the “Patient Special Diet Information”
report which lists the number and type of meals required.
6.11.3.2. Originating MTF Patient administration desk (PAD)/AE Clerk ensures diet
orders are recorded in the PMR through TRAC2ES in accordance with Theater OPORD
and/or local directives.
6.11.3.3. Originating and/or en route joint Base Operating Support (BOS), contracting
food services, flight kitchens, staging facilities and MTFs provide patient and attendant
regular diets, snacks, beverages, and bulk food, and may fill special diet requirements
under the direction of dietetic/nutritional medicine/nursing personnel.
6.11.3.4. Aircraft refrigerators/coolers may be used if available for patient nourishment
items, with coordination and approval from the loadmaster/boom operator and/or PIC.
Table 6.1. Planning Patient Meals and Snacks.

Flight
Refrigerator Available No Refrigerator Available
Time
Snacks and beverages (1) if not Snacks and beverages are not
Less than over mealtime over mealtime
4 hours Box lunch (2) or frozen entree Box lunch (2) or MRE (3) and
meal and beverages (1) beverages
2 meals 2 meals
More than 1 box lunch (2) and 1 frozen meal 1 box lunch (2) and 1 MRE
8 hours
and beverages (1) (3) and beverages (1)
OR OR
1 MRE (3) and snacks and
2 frozen meals and beverages
beverages (1)
Each Add additional snacks and
Add additional frozen meal and
additional
beverages (1) beverages (1)
4 hours
Notes:
1. Shelf stable and does not require refrigeration.
2. Includes sandwiches. Considered “safe” to consume within 4 hours of issue
from a food service facility if not stored in a refrigerator at or below 41º F.
Avoid using mayonnaise.
3. Only when no other shelf-stable food is available. Do not use MRE heaters
in-flight.
6.11.3.5. Request infant/child meal food items by specifying the child’s age on the diet
order request. Pediatric nutrition needs assessment/screening criteria includes an
assessment of weight for age, weight loss, special dietary needs, food allergies, chronic
illnesses, and nutrition education needs.
6.11.3.6. The originating, or en route privileged provider, writes diet orders including
tube feedings on the EHR or AF Form 3899.
6.11.4. Total parenteral nutrition infusions may continue until complete then switch to 10%
Dextrose in Water.
6.11.5. Food safety.

6.11.5.1. At operationally feasible locations, potentially hazardous/non-shelf stable foods
(meat, eggs, and milk products) are maintained either below 41º F or above 140º F in
order to remain safe.
6.11.5.2. Use commercially prepared shelf-stable food available through local prime
vendor source whenever possible. Meals Ready to Eat (MREs) are used if other shelf-
stable food is unavailable.
6.11.5.3. Depending on the location, water and ice sources may not be adequate, so
bottled water may be required. Follow commander’s OPORD, CCMD’s FHP guidance
and/or local directives.
6.11.5.4. Staging facilities, ground transportation vehicles, and aircraft may lack
adequate equipment to store food at safe temperatures.
6.11.5.5. Food-borne illnesses are a threat to the health of all personnel. Patients who are
compromised have an increased risk of food-borne illness. Personal hygiene, food safety,
and sanitation practices are critical for all personnel responsible for patient feeding.
Follow safe food handling practices and limit access to food preparation areas. Personnel
handling and preparing food items wash hands with soap and water or use hand sanitizer
prior to contact with any food items. Patients are also instructed to wash their hands
(reference paragraph 8.25).
6.11.5.6. After meals are consumed, and before leaving the patient care area, all nursing
personnel check used box lunches/patient trays for possible contamination (e.g., syringes,
wound dressings, body fluids) before disposal and/or cleaning.
6.11.6. Insulated Containers/Coolers.
6.11.6.1. If operationally feasible and available, pack patient meals/special diets in
insulated containers, with ice, and deliver to the patient departure point for loading onto
the aircraft or transportation asset.
6.11.6.2. Unsealed food items, medications, and blood products are prohibited in food
refrigerators and food items are not permitted in biomedical refrigerators.
6.11.6.3. Usually there is no temperature reading device or power associated with these
units, and temperatures are not evenly distributed. Temperature ranges are 34° to 40° F
for the food refrigerators.
6.11.6.4. Monitor ground UTC internal refrigerator temperatures at least three times a
day with a refrigerator thermometer and record on a locally developed temperature chart.
6.11.6.5. Fleet services clean aircraft refrigerators used for patient food pre and post-
mission.
6.11.7. PMRC.
6.11.7.1. Provide diet information to the ERPS or the originating MTF.
6.11.7.2. Submit PM/AE diet orders and bulk food requirements to MTF
dietetic/nutritional and/BOS food support personnel at locations without an ERPS.
6.11.7.3. Complete diet order request and fax diet orders to the appropriate MTF
according to patient’s special diet requirements identified in TRAC2ES.
6.11.8. ERPS or originating facility.
6.11.8.1. Each MTF/ERPS contacts their designated patient administration desk/AE
clerk or AELT to coordinate ground and aircraft arrivals and departures for meal
delivery.
6.11.8.2. If a staging facility is in place, the staging facility charge nurse ensures patient
meals are ordered on AF Form 1094, Diet Order. If available, Nutritional Medicine
coordinates patient feeding requirements with BOS elements. If there is not a staging
facility, the AEOT Senior Nurse, or AECM, ensures patient meals are ordered.
6.11.8.3. Update TRAC2ES diet orders/requirements as required. In the event of altered
transportation plans, the originating MTF or ERPS obtains adequate nutritional
provisions for patients and provides 1-day tube feeding supply for intra-theater PM and
three-day supply for inter-theater PM.
6.11.8.4. Submit diet and bulk food orders to dietetic/nutritional support personnel at
least four hours before aircraft departure time or in accordance with local directives.
6.11.8.5. Deliver patient meals to patient care areas and aircraft in coordination with
local Public Health Officer and/or FS if applicable.
6.11.8.6. Clean/disinfect refrigerators used to store patient nourishments after each use.
Clean/disinfect insulated transportation containers/coolers and return to supporting food
service agency (reference paragraph 8.25).
6.11.9. AECMs.
6.11.9.1. Check that meals are available and received.
6.11.9.2. Coordinate meal storage requirements and feeding times with PIC and/or
loadmaster/boom operator.
6.12. Patient Briefings.
6.12.1. The sending facility, ERPS, and AE crews (AECMs reference AFMAN 11-2AEV3)
ensure each patient/attendant receives an informational briefing explaining what the patient
can expect during their flight. These briefings are customized for each theater of operations
(e.g., USAFE, PACAF, CONUS) to provide essential information. Thorough preflight
briefings completed prior to take off reduce stress (reference Attachments 3, 4, & 5.). Note:
This requirement may be impractical during contingency operations.
6.12.2. ERPS or Originating Facilities Briefings. Brief patients and attendants during routine
operations on AE and staging policies and procedures to include the following:
6.12.2.1. Force protection issues.
6.12.2.2. Unauthorized items are confiscated.
6.12.2.3. Anti-hijacking requirements.
6.12.2.4. Route of evacuation, including the estimated time and the number of planned
stops (when known). Notifying patients and attendants that the itinerary is subject to
change.
6.12.2.5. Potential for unscheduled overnight stops.
6.12.2.6. Baggage limitation, including weight and size according to the baggage section,
or exceptions, is annotated on the patients’ travel orders.
6.12.2.7. Place a copy of the TDY travel order or travel authorization in each piece of
stowed and hand-carried luggage.
6.12.2.8. The need for personal funds, medical supplies, medications, and appropriate
dress.
6.12.2.9. U.S. Department of Agriculture and Customs inspections procedures.
6.12.2.10. Use of restrooms prior to departing for the flight line.
6.12.2.11. Do not place the following items in checked bags; x-rays, medical records,
and medications (if authorized to “self-medicate”). These items are hand carried.
6.12.2.12. Procedures and patient requirements during transport to aircraft.
Chapter 7
FLIGHT PHYSIOLOGY AND STRESSES OF FLIGHT
7.1. Flight Environment. AE occurs in a physically constrained, relatively hypoxic, hypobaric,

noisy, vibrating, unclean environment with wide temperature shifts differing significantly from
the MTF. Physical stresses during flight affect not only every patient’s physiology and
psychology but can impair medical providers’ abilities to assess and deliver care while airborne.
Patients in the AE environment are susceptible to physiologic stresses encountered at altitude.
7.2. Gas Laws.
7.2.1. Dalton’s Law of partial pressure. Dalton’s gas law states the total pressure of a
mixture of gases is equal to the sum of the partial pressures of each gas within the mixture.
Barometric/atmospheric pressure is the pressure exerted against an object by the atmosphere.
Therefore, as altitude increases and barometric pressure decreases and there is a
corresponding decrease in the partial pressure of inspired oxygen, even for patients on
ventilators with 100% O2. Oxygen concentration remains 21% regardless of altitude.
Barometric pressure multiplied by the concentration of gas is equal to the partial pressure of
the gas. As altitude increases, the partial pressure of a gas decreases. The actual available
oxygen decreases with altitude because oxygen molecules move farther apart, possibly
resulting in hypoxia. As pressure decreases, O2 has a harder time crossing into the blood
stream, resulting in a decreased O2 saturation (SpO2) of the blood. For example, at an
altitude of 10,000 ft., partial pressure of oxygen in arterial blood (PaO2) would measure
approximately 51 millimeters of Mercury (mmHg), yielding a SpO2 of approximately 84%
in a healthy individual.
7.2.2. Charles’ Law: When the pressure is constant, the volume of gas is proportional to its
temperature. Likewise, if volume remains constant, the pressure on the gas varies directly
with temperature. During flight, temperature decreases an average of 3.5 Fahrenheit or 2
Celsius per 1000 ft., therefore, ambient temperature for an aircraft flying at 35,000 ft. can be
expected to be near -57F. Such a reduction in temperature results in a significant drop in
oxygen tank pressure if exposed; conversely oxygen tank pressure can be expected to rise
with significant increases in ambient temperature.
7.2.3. Henry’s Law: The principle of evolved gas disorders. The solubility of gases in
liquids: The quantity of gas dissolved in 1 milliliter (ml) of a liquid is proportional to the
partial pressure of gas in contact with the liquid. The weight of gas dissolved in a liquid is
directly proportional to the weight of the gas above the liquid. An example is shaking a can
of soda and opening it immediately. The balance of pressure is altered, releasing the bubbles
of gas in the soda. During a rapid decompression, the same principle applies where nitrogen
bubbles are released into the blood following the dramatic changes in aircraft pressurization.
This relationship explains why dissolved nitrogen transitions to a gas phase in blood and
tissues during decompressions.
7.2.4. Boyle’s Law: The principle of gas expansion. Boyle’s Law states at a constant
temperature, the volume of gas is inversely proportional to the pressure. During ascent
(decompression), gasses expand and during descent (recompression), gasses contract. For
instance, a climb to flight level 180 from sea level (SL) results in a 50% reduction in total
barometric pressure accompanied by a 50% increase in gas volume. However, the constant
pressure (47 millimeter of Mercury [mmHg]) of water vapor within the body contributes to
physiological gasses expanding at a slightly greater rate than atmospheric gasses therefore
resulting in a 50% increase in gas volume at 16,500 feet (1,500 feet lower than atmospheric
gasses). One example is the volume of gas in a balloon expands at altitude.
7.2.5. Graham’s Law: The law of gaseous diffusion. Gases flow from higher pressure (or
concentration) to a region of lower pressure (or concentration). Simple diffusion or gas
exchange at the cellular level is an example.
7.3. Physiological Stressors of Flight. The stressors of flight can be broadly categorized into
two classes: those which can quickly incapacitate the patient and crew and those which can
aggravate medical conditions. In certain age groups, (e.g., neonates) irritant stressors, such as
extreme cold, can be life threatening. The patients’ ability to withstand the physiologic effects of
flight stressors vary depending upon their underlying disease processes and their age. Patients are
exposed to barometric pressure changes, decreased partial pressure of oxygen, decreased
humidity, temperature variations, high noise levels, vibration, travel fatigue and gravitational-
forces.
7.3.1. Barometric Pressure Changes (Boyle’s Law). Gas volume changes are physiologically
significant in AE. The mechanical effects of expansion and contraction can exert a
differential pressure on the surrounding tissues, which can cause severe, potentially disabling
pain and potential physical damage to tissues (e.g., ear, sinus, GI tract, and lungs). Air filled
balloon devices (e.g., foleys, g-tubes) are usually be filled with normal saline (NS) by the
originating MTF to avoid the repeated pressure exposure by expansion/contraction of the
balloons during changes in altitude. Endotracheal tubes are filled with air and monitors by
the CCATT team with a pressure manometer. Small pockets of air within fluid can cause
damage to the trachea. AECMs ensure this precaution has been accomplished to prevent soft
tissue damage and/or irritation.
7.3.1.1. A cabin de-pressurization may result in decompression sickness.
7.3.1.2. If a patient experiences adverse symptoms related to barometric pressure
changes, the clinician documents the maximum cabin altitude at the time of the incident.
7.3.2. Decreased Partial Pressure of Oxygen (Dalton’s Law). Dalton’s Law more
significantly affects patients with cardiac disease, pulmonary disease, anemia, trauma, and
increased intracranial pressure. These patients may quickly experience vital end-organ
dysfunction when exposed to altitude hypoxia and require supplemental oxygen therapy as
ordered.
7.3.2.1. Increased oxygen or delivery pressures may be required when at altitude.
7.3.2.2. Follow the AE Clinical Protocol for Emergency Oxygen if supplemental oxygen
is needed, call C2 and the PMRC to obtain an order as soon as possible and initiate a
JPSR worksheet or DD Form 2852. If an ERCC team doctor is on board, they can write
the order but also notify C2 and the VFS. Note: A pulse oximeter is available on board
AE aircraft, but referring privileged providers recognizes these devices can give
erroneously higher readings under certain physiologic conditions (e.g., carbon monoxide
poisoning, dehydration, anemia, impaired peripheral circulation, and high or low cardiac
output states). Note: A cabin altitude restriction is sometimes required in addition to
supplemental oxygen therapy (reference Chapter 8 for cabin altitude restrictions) and
AE Clinical Protocol – Emergency Oxygen.
7.3.3. Decreased Humidity. The partial pressure of water (e.g., humidity) of cabin air
decreases as altitude increases. When air is cooled, it loses its ability to hold moisture. Air at
altitude is cold, possessing little moisture (e.g., the higher the altitude, the colder and drier
the air is). The fresh air supply is drawn into the aircraft cabin from a very dry atmosphere.
Extended flying time magnifies the drying effects of exposure to altitude.
7.3.3.1. Cabin humidity can be less than three percent (3%) toward the end of a long
mission. Resulting dehydration and thickened secretions can affect pulmonary patients.
Use humidification bottles for all patients receiving oxygen to keep the secretions loose
in the lower respiratory tract.
7.3.3.2. Patients with fluid balance problems, (e.g., patients with renal and cardiac
diseases or respiratory compromise), are at significant risk and have strict intake and
output (I&O) ordered (oral and/or IV). Plan to provide hydration to all patients as
required.
7.3.3.3. Wounds requiring moist packing may dry out quickly during airlift. Treatment
orders need to specify wound care objectives such as reinforcing dressings and providing
additional solutions to the wound.
7.3.3.4. Nothing by mouth (NPO) patients require hydration status via intravenous fluids
(IVF). Their IVF rates would need to be slightly increased, compared to usual MTF rates.
7.3.4. Temperature Variations. An increase in altitude results in a decrease in ambient
temperature. Aircraft cabin temperature fluctuates considerably depending on the
temperature outside the aircraft. Temperature fluctuations on the flight line and in the aircraft
can be extreme.
7.3.4.1. Patients with burns/skin-damage, who are critically ill, sedated, mentally altered,
elderly, or infants can succumb to hypothermic conditions that may often occur on
military aircraft.
7.3.4.2. An air worthy certified incubator can be used to provide warmth for infants
under 10 pounds.
7.3.4.3. Blankets are available in flight. Prior to the flight, the originating facility ensures
the patients are prepared for temperature fluctuations in-flight.
7.3.4.4. When traveling at extreme temperatures, monitor portable oxygen source
pressures.
7.3.5. High Noise Levels. Noise is a problem in all aircraft. To reduce gross weight and thus
maximize fuel savings, military aircraft are not equipped with noise shielding materials
found on modern civilian commercial aircraft.
7.3.5.1. Noise interferes with the ability of providers to assess vital signs (VS),
auscultate, and communicate with patients including deescalating/monitoring psychiatric
patients, and detecting equipment alarms while on board the aircraft.
7.3.5.2. Patients, passengers, crews, and attendants are provided hearing protection prior
to flight. Alternate methods of communication may be required.
7.3.6. Vibration. When the human body is in direct contact with a source of vibration,
mechanical energy is transferred, which is degraded into heat within those tissues that have
dampening properties. The response to whole body vibration is an increase in muscle activity
both to maintain posture and to reduce the resonant amplification of body structures. This is
reflected in an increase in metabolic rate, a redistribution of blood flow with peripheral
vasoconstriction, and increased oxygen requirements. The increase in metabolic rate during
vibration is comparable to that seen in gentle exercise and respirations are increased to
achieve the necessary elimination of increased carbon dioxide. Additionally, disturbances in
visual acuity, speech, and fine-muscle coordination result from vibration exposure.
7.3.6.1. Vibration may cause increased pain for many patients. Orthopedic patients often
benefit from pain medication administered during preflight before exposure to vibration.
Additional padding/cushioning of stabilizing devices (e.g., casts, external fixators,
braces) and supportive techniques can help relieve discomfort from vibration.
7.3.6.2. Equipment can be affected by vibration and settings require close monitoring.
7.3.6.3. Originating privileged providers order a pain control regime to include PRN
orders.
7.3.7. Turbulence. Turbulence can be produced by high and low temperature changes in the
outside air. Turbulence increases stress during flight by promoting fatigue and increasing
susceptibility to motion sickness and disorientation.
7.3.7.1. Turbulence may easily overwhelm and incapacitate someone suffering from
other medical conditions, (e.g., chemotherapy, pregnancy, or patients prone to motion
sickness). PRN anti-emetic order is recommended. In the event nausea and vomiting are
already present, medicate the patient prior to arrival at the aircraft and have PRN orders
written.
7.3.7.2. All patients, equipment, and supplies are secured in accordance with AFMAN
11-2AEV3 and AFMAN 10-2909.
7.3.8. G-Forces. The effects of G-Forces involve an understanding of the concepts of exerted
forces. Speed, velocity, weight, mass, and the laws of motion are among those
considerations. Specific perils from the effects of G-Forces can include deterioration of
vision and disturbances of consciousness related to high-performance aircraft. Newton’s First
Law of Motion states unless acted upon by a force, a body at rest remains at rest, and a body
in motion moves at constant speed in a straight line.
7.3.8.1. Findings, such as increased intracranial pressure (ICP), pregnancy, unstable
fractures and blood pooling are conditions to consider when examining effects of G-
Forces in AE. To reduce the effects of G-forces, extra padding may be used on the
abdomen and seat belt for small children, pregnant women, and patients with abdominal
surgery.
7.3.8.2. Patients with head injuries may be loaded head forward and facing aft at the
discretion of the VFS or ERCC team physician when applicable and after communication
with the MCD.
7.3.9. Fatigue. All the stresses of flight induce fatigue to some degree and are an inherent
stress in the AE environment. Erratic schedules, multiple platforms over several days,
hypoxic environment, noise, vibration, and imperfect environmental systems eventually take
their toll.
7.3.9.1. Travel through multiple time zones may cause bodily circadian rhythm
disruption or jet lag, also characterized by symptoms of fatigue and irritability. Order
"litter for comfort" for patients who cannot tolerate prolonged sitting.
7.3.9.2. Consider the following human systems factors which may lead to stress/fatigue.
The acronym DEATH may assist in remembering the factors.
7.3.9.2.1. D rugs. Use of over the counter (OTC) medications, misuse of prescription
medications, and use of stimulants such as caffeine can cause insomnia, tremors,
indigestion, and nervousness.
7.3.9.2.2. E xhaustion. Exhaustion can lead to judgment errors, limited response,
falling asleep, channeled attention, and changes in circadian rhythm.
7.3.9.2.3. A lcohol. Using alcohol may cause histotoxic hypoxia, which is a
deficiency of oxygen reaching the bodily tissues due to impairment of cellular
respiration especially by a toxic agent such as alcohol. Histotoxic hypoxia affects
efficiency of cells to utilize oxygen, interferes with metabolic activity, and can result
in a hangover.
7.3.9.2.4. T obacco. Besides exposing the body to tar, nicotine and carcinogens, the
average smoker normally has 5 to 10 % hemoglobin involved as carboxyhemoglobin.
This results in hypemic hypoxia (reduces the oxygen carrying capacity of the blood)
and lowers altitude tolerance. Flying at a cabin altitude of 10,000 ft. with 10%
carboxyhemoglobin is physiologically equivalent to 15,000 ft.
7.3.9.2.5. H ypoglycemia. Poor dietary intake can cause nausea, headache,
dizziness, and judgment errors.
Chapter 8
PATIENT CARE RESPONSIBILITIES
8.1. Aeromedical Evacuation Clinical Protocols.

8.1.1. Standing orders are signed by En Route Care Medical Director in AMC/SGK.
8.1.2. Consult an ERCC team doctor in-flight, if available, for any clinical situations that
may arise. Call C2 and the PMRC to obtain an order as soon as possible and initiate a JPSR
worksheet or DD Form 2852.
8.1.3. Are maintained on the EFB and AMC/A3/SG site (reference Attachment 2, A2.1.1).
8.1.4. The AECM documents the use of AE Clinical Protocol in the EHR or AF Form 3899.
All AECP documentation includes the statement “in accordance with AE Clinical Protocol -
XXX”.
8.2. Preflight Assessment and Report. Patient acuity, mission requirements, and the
environment determines how extensive this process is. Obtain as much history as possible from
the patient, PMR, and patient records using the Identify, Situation, Background, Assessment, and
Recommendation (I-SBAR) format found in Attachment 7 & 8.
8.2.1. In the AE environment, the primary assessment skills are inspection and palpation.
Primary and secondary trauma assessment skills are used to quickly identify and treat life-
threatening conditions. Note: Auscultation is not reliable during in-flight assessments.
8.2.1.1. During flights shorter than 45 minutes, as appropriate and per diagnosis,
clinicians assess for allergies, immediate patient concerns/interventions required, suicidal
ideations/homicidal ideations, restraints or constrictive devices, VS, pain level, sedation
score (reference Table 8.10), circulation, motor and sensory function. Note: Operational
constraints may limit completion of these tasks.
8.2.1.2. Clinicians assess patients for abnormal respiratory findings to include respiratory
adjuncts.
8.2.1.3. Clinicians assess patient’s ability or inability to self-medicate, and any other
clinical findings suggesting a decreased sensorium and/or altered judgment.
8.2.2. Primary Survey. Accomplished when the patient is initially seen by medical
personnel, such as at a first aid station, MTF, ERPS or at the flight line. Life threatening
conditions are identified, and management begins. Ensure this is done prior to flight.
Reassessment of circulation, airway, and breathing is ongoing.
8.2.2.1. Circulation.
8.2.2.2. Airway.
8.2.2.3. Breathing: Ventilation and oxygenation.
8.2.2.4. Disability: Brief neurologic examination to establish level of consciousness
(LOC).
8.2.2.4.1. The following is a MNEMONIC for differentiating the causes and
treatment coma/unresponsiveness:
8.2.2.4.2. U – Units of Insulin

8.2.2.4.3. N – Narcotics
8.2.2.4.4. C – Convulsions
8.2.2.4.5. O – Oxygen
8.2.2.4.6. N – Non-Organic
8.2.2.4.7. S – Stroke
8.2.2.4.8. C – Cocktails
8.2.2.4.9. I – Intracranial Pressure
8.2.2.4.10. O – Organism
8.2.2.4.11. U - Urea
8.2.2.4.12. S - Shock
8.2.2.5. Exposure/environment: If condition and situation warrants, completely undress
the patient. Prevent hypothermia, if possible.
8.2.3. General appearance:
8.2.3.1. The patient’s body position noting posture and any guarding or self-protection
movements.
8.2.3.2. Observe for stiffness, rigidity, or flaccid muscles.
8.2.3.3. Observe unusual odors such as alcohol, gasoline, chemical, vomitus, urine, or
feces.
8.2.4. Secondary survey. This assessment is a brief, systematic process to identify ALL
injuries, obtain history and mechanism of injury as well as maintaining core body
temperature, obtaining a complete set of VS, temperature, pulse oximetry, and the insertion
of adjuncts such as a urinary catheter and nasogastric tube (NG), as required.
8.2.4.1. Full VS (blood pressure [BP], pulse, respirations, pulse oximetry, temperature),
pain level, history, cardiac monitor, and pulse oximeter applied as necessary.
8.2.4.2. Give comfort measures (verbal reassurance, pain assessment, and
pharmacologic/non pharmacologic).
8.2.4.3. History and head-toe assessment (if condition and situation warrants).
8.2.4.4. Include face, neck, chest, pelvis/abdomen, extremities.
8.2.4.5. Inspect back and posterior surfaces.
8.2.4.6. Reference American Heart Association (AHA) or equivalent, Trauma Nurse
Core Course (TNCC) if available and current and DHA/J7 Education and Training
guidelines.
8.2.5. Ongoing assessment/re-assessment. Reevaluate the patient noting, reporting, and
documenting any changes in the patient’s condition and responses to resuscitative efforts.
Time, personnel, and environment determines this re-evaluation process.
8.3. General Nursing Care.

8.3.1. A plan of nursing care is developed or modified using the patient’s chart and other
information, to assure continuity of care. The patient is observed throughout all phases in the
AE system. The appropriate level and type of medical and psychological care measures are
rendered by AE, CCATT or ERPS personnel, as described in this chapter.
8.3.2. Maintain strict patient confidentially (on a need-to-know basis), as related to HIPAA
rules and regulations, in reviewing or releasing any medical information.
8.3.3. Patient comfort. If the ambient temperature exceeds a comfortable level, the AECM
can speak with the PIC and or the Loadmaster/Boom Operator to correct the temperature.
Whenever possible, to prevent hypothermia in critical care patients, temperature in the
aircraft is kept warmer than normal.
8.3.3.1. Latrine facilities. Inform litter patients urinals, bedpans, and modesty curtains
are available. Ensure patients have the opportunity to use the restroom before being
transported to the aircraft and prior to critical phases of flight.
8.3.3.2. Oral hygiene. Dried secretions accumulated on the tongue and palate reduce oral
sensitivity and promote bacterial growth. Mouth care, especially for debilitated patients,
is essential because of the reduced humidity in the aircraft cabin. Comatose, paralyzed,
and other patients at risk receive mouth care at least every two hours Note: When a
toothbrush and toothpaste is contraindicated, disposable foam swabs are an acceptable
substitution.
8.3.3.3. Position changes. Any position, even the most comfortable one, may have an
adverse effect on a patient over time. A patient’s movements may be limited by disease,
injury, or helplessness. Position changes promote comfort and relaxation, prevent skin
breakdown, and improve gastrointestinal and respiratory function. Position changes are
completed at least every two hours.
8.3.4. Straps/stanchion arms can be adjusted two inches up or down to allow for position
changes to reduce pressure points on litter patients. A blanket roll, lift sheets or backrest may
also assist in shifting the patient’s weight and keeping heels off the litter to relieve pressure.
8.3.5. Range of motion (ROM) exercises are utilized whenever possible.
8.3.6. The Braden Scale is used throughout the DoD Medical Service to identify patients at
risk for developing skin breakdown or pressure ulcers. Factors predisposing a patient to
develop pressure ulcers include decreased mobility, activity, and sensory perception;
increased moisture, friction, and shear forces; and intrinsic factors influencing tissue
tolerance associated with age, nutrition, and tissue perfusion. The Braden Scale uses these
factors to provide a score 6-23. AECMs and ERPS staff are familiar with these scores for
purposes of awareness and documentation during hand-offs from MTFs and the need for
intervention to minimize pressure ulcer development or worsening during flight (reference
Attachment 9).
8.3.7. Patient ambulation. Encourage ambulation every two hours to prevent venous
thromboembolism (VTE) for patients whose condition allows. Ambulatory patients are
encouraged to stand up and stretch to promote circulation to the extremities. Litter patients
are ambulated, assisted to the lavatory and allowed to sit in a seat, if possible. Ensure
adequate pain control. Any complaints of calf tenderness or new posterior leg pain is
evaluated for VTE pre/post transport (reference paragraph 8.6).
8.3.8. Reduce fatigue. All patients are susceptible to the effects of fatigue. Litter patients
require special planning and care to reduce fatigue. Note: Nursing interventions counter
these stresses of flight. Provide ear plugs, blankets, and pillows. Dimming the lights in-flight
provides an atmosphere for sleep and relaxation. An uncomfortable position may hinder
sleep more than the vibration and noise of the engines.
8.3.9. Skin care. Disposable washcloths are available and can be placed in a plastic bag,
dampened with hot or cold water, and distributed to the patients. Antiseptic towelettes or
liquid hand sanitizer are made available and offered before meals and after a patient uses a
urinal, bedpan, or latrine.
8.3.10. Monitor I&O as condition warrants.
8.3.10.1. Intake: All those fluids entering the patient's body such as oral fluids, ice
chips, parenteral, IVF, feeding tubes, irrigation, and blood transfusion.
8.3.10.2. Output: All fluid that leaves the client's body such as urine, diarrhea, vomiting,
and drainage from all tubes and bleeding.
8.4. Airway and Respiratory Management.
8.4.1. Stresses of flight affecting airway and respiratory management.
8.4.1.1. Decreased partial pressure of oxygen: Exacerbates possible oxygenation
deficiencies due to a compromised respiratory system and diminished ciliary action.
8.4.1.2. Barometric pressure changes: May cause spontaneous pneumothorax in a
trauma patient with significant respiratory compromise. GI gas expansion may cause
diaphragmatic crowding leading to lower tidal volumes.
8.4.1.3. Thermal: Both an increase or decrease in body temperature increases the
metabolic rate and O2 demand on the body (particularly true in ventilator dependent
patients).
8.4.1.4. Decreased humidity: The effectiveness of ciliary action is decreased, resulting
in thickened secretions.
8.4.1.5. Fatigue: Most patients with respiratory disorders are already fatigued from the
added workload of breathing. The overall effect of the previously mentioned stresses of
flight and the total length of time in the AE system may increase fatigue and exacerbate
the patient’s condition.
8.4.1.6. Gravitational Forces: The positive gravitational forces generated on
takeoff/ascent may cause diaphragmatic crowding, fatigue, and exacerbate the patient’s
condition.
8.4.2. Assessment of respiratory status.
8.4.2.1. Determine the mechanism of injury or disease. Look, listen and feel for
indicators requiring possible intervention. The flight environment may preclude
auscultation. If appropriate, obtain a baseline oxygen saturation.
8.4.2.2. Assess and document the following as dictated by the patient’s condition:
8.4.2.2.1. Respiratory rate, depth, symmetry, oxygen saturation and maximum cabin
altitude.
8.4.2.2.2. Document if any of the following abnormal findings are present.
8.4.2.2.2.1. Any use of accessory muscles, intercostal and substernal retractions,
stridor, nasal flaring, pursed-lip breathing, prolonged expiration, skin color and
position of patient.
8.4.2.2.2.2. Tongue obstructing the airway in an unconscious victim.
8.4.2.2.2.3. Loose teeth and/or other foreign objects.
8.4.2.2.2.4. Facial and/or oral bleeding.
8.4.2.2.2.5. Facial fractures resulting in loss of maxillary and mandibular
structural integrity.
8.4.2.2.2.6. Inhalation injury or nasal/mucosal charring.
8.4.2.2.2.7. Tracheal edema.
8.4.2.2.2.8. Hematomas, bruising, wounds, and crepitus of the neck and upper
chest.
8.4.2.2.2.9. Position of trachea (midline or deviated).
8.4.2.2.3. Glasgow Coma Scale (GCS): A score of less than 8 may suggest
concurrent findings of hypoxia and require intubation (reference Table 8.1).
Table 8.1. Glasgow Coma Scale.

Adult Child
Eye Opening
No Response 1 None 1
Opens to Pain 2 Opens to Pain 2
Opens to Speech 3 Opens to Verbal 3
Opens 4 Opens Spontaneously 4
Spontaneously
Verbal Response
Incomprehensible 2 Moans to Pain 2
Inappropriate words 3 Persistent Cry to Pain 3
Confused 4 Inconsolable Cry to Pain 4
Oriented 5 Appropriate Words/Coos 5
Motor Response
Extension to Pain 2 Extension to Pain 2
Flexion to Pain 3 Flexion to Pain 3
Withdraws to Pain 4 Withdraws to Pain 4
Localizes Pain 5 Localizes Pain 5
Obeys Command 6 Spontaneous Movement 6
Score interpretation: E+V+M=

9-13 Moderate Brain Injury
3-8 Sever Brain Injury
<8 May suggest concurrent findings of hypoxia and
require intubation
8.4.2.2.4. Severe respiratory distress or status epilepticus may require sedation or
paralyzing agents to secure airway. Note: The AE in-flight kit does not contain
paralytic drugs.
8.4.3. Preflight/in-flight considerations and care for respiratory patients.
8.4.3.1. Assure sufficient O2 is available in all phases of transport (including portable for
ground transport if required).
8.4.3.2. Maintain a patent airway with positioning, suctioning, and adequate humidified
oxygen. Note: Administer oxygen for any signs of hypoxia and respiratory distress or
significant change from original assessment.
8.4.3.3. Respiratory disease pathologies may require additional preflight evaluation and
possible cabin altitude restriction. Some of the more common diagnoses include, but are
not limited to:
8.4.3.3.1. Chronic obstructive pulmonary disease (COPD). COPD includes
pulmonary emphysema, chronic bronchitis, and status asthmaticus.
8.4.3.3.2. Restrictive lung disease: Extensive pneumonic consolidation, aspiration
pneumonia, pulmonary atelectasis and infarction, pulmonary contusions, acute
respiratory distress syndrome (ARDS), pulmonary edema, and hemothorax and/or
pneumothorax.
8.4.3.3.3. Any disease or physiological process dependent upon oxygen delivery such
as extensive tumors, granulomatous processes, lymphatic spread of carcinoma,
diffuse parenchymatous diseases, alveolar proteinosis, sarcoidosis, interstitial fibrosis,
shock, cardiac disease, and traumatic brain injury (TBI).
8.4.3.4. Cabin altitude restriction and supplemental oxygen: The decision for cabin
altitude restriction or supplemental oxygen is based on the individual patient needs, the
VFS orders, and the following considerations:
8.4.3.4.1. Most AE aircraft (C-17 and KC-135) cruise with a cabin altitude of 6,000 –
8,000 ft. At a 7,000 ft. altitude, a healthy person’s PaO2 is 60 mmHg or about 90
percent saturation. Patients with a sea level PaO2 below 60 mmHg (90 percent
saturation) potentially have difficulty with hypoxic hypoxia while in-flight.
8.4.3.4.2. Patients with COPD are administered low flow oxygen therapy (1 to 2
liters per minute via nasal cannula [NC] or Venturi mask) to avoid suppression of
their hypoxic drive. Closely monitor respiratory rate if receiving higher
concentrations of O2. Request lower cabin altitude if unresponsive to high flow O2
and operationally feasible. Complete a JPSR worksheet or DD Form 2852.
8.4.4. Urgent airway management.

8.4.4.1. Airway obstructed or partially obstructed:
8.4.4.1.1. Position patient to allow for maximum ventilation. Consider a backrest if
not contraindicated.
8.4.4.1.2. Open and clear the airway (reference AHA or equivalent, TNCC if
available, and DHA/J7 Education and Training guidelines).
8.4.4.1.3. Suctioning (do not invoke a gag reflex).
8.4.4.2. Advanced airway treatment/management: In general, advanced airway
procedures such as oral/nasal intubation, cricothyrotomy, and tracheostomy procedures
are not normally performed by AECMs. Specially trained healthcare professionals,
working within their AFSC scope of practice, may perform those procedures. The
benefits of the procedure outweighs the risks of not performing the procedure in the AE
system. Any change in a patient’s status is reported to C2 and PMRC for further guidance
and a JPSR worksheet or DD Form 2852 is submitted.
8.4.5. General clinical guidelines for all respiratory patients.
8.4.5.1. O2 delivery methods are outlined in Table 8.2
Table 8.2. O2 Delivery Methods.

Reference AHA or equivalent, TNCC if available, and DHA/J7 Education and
Training guidelines on practices and assessment skills.
METHOD Liters Per Minute (LPM) O2%
NC Low flow-O2 Increasing O2 flow by 1
delivery mixes with LPM increases inspired
ambient gas. Inspired O2 concentration by
O2 concentration approximately 4%.
depends on the flow 1 24
rate and the patient’s 2 28
tidal volume. 3 32
4 36
5 40
6 44
Face Mask-Administer
10 60
6 to 10 LPM
Non-rebreather mask 10 -15 LPM > 90%
with O2 reservoir
(constant flow of O2
enters the attached
reservoir). Administer
10-15 LPM via a tight-
fitting mask for
patients who require a
rapid clinical
effect/high-flow O2.
Note: Requires close

monitoring for nausea
and vomiting. Suction
is readily available.
Venturi Mask Use for in accordance with 24

patients who retain manufacturer’s 28
CO2. Initially use 24%, guidelines. 35
unless otherwise 40
ordered, and observe
for respiratory
depression. Note: Not
supplied in the AE
IFK.
8.4.5.2. In the most serious cases, give high flow O2 @ 100% via non-rebreather mask
or bag valve mask (BVM).
8.4.5.3. Deliver humidified O2 whenever possible. Monitor sterile water levels in
humidification bottles.
8.4.5.4. Monitor pulse oximetry (O2 saturation) and titrate O2 up or down accordingly to
maintain at least 92% or as directed by VFS.
8.4.5.5. In patients with low hemoglobin states, supplemental O2 is ordered by the VFS
per Table 8.3
8.4.5.6. Table 8.4 outlines the effect of altitude on delivered oxygen levels and converts
what is required on the ground to what the increase requirements is at altitude.
Table 8.3. Oxygen Requirements for Low Hemoglobin States.

PATIENT’S CONDITION IN-FLIGHT O2
REQUIREMENTS
Chronic low hemoglobin states
8.5 – 10 PRN Oxygen Available

7.0 – 8.5 Oxygen 2L for flight
Below 7.0 As directed by the VFS
Acute low hemoglobin states
9.0 - 10.0 Oxygen Available

8.0 – 9.0 Oxygen 2L for flight
Below 8.0 As directed by the VFS
Table 8.4. Conversion for In-flight Oxygen Administration.

Altitude Oxygen Percentage
10,000 30 36 44 51 58 65 73 80 87 94 100
*
9,000 29 35 42 49 56 63 70 77 84 91 98 100
*
8,000 28 34 40 46 54 61 67 74 81 87 93 100
*
7,000 27 32 39 45 52 58 65 71 78 84 91 97 100
*
6,000 26 31 37 44 50 56 62 69 75 81 87 94 100
*
5,000 25 30 36 42 48 54 60 66 72 78 84 90 96 100
*
4,000 24 29 35 41 46 52 57 64 70 75 81 87 93 97 100
*
3,000 23 28 33 39 45 50 56 61 67 73 78 84 89 95 100
*
2,000 23 27 32 38 43 48 54 59 64 70 75 81 86 91 97 100*
1,000 22 26 31 38 41 47 52 57 62 67 73 78 83 88 93 98 1
0
FiO2 21 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 1
0
0
Desired Sea Level Equivalent Oxygen Percentage
0
*Even though the delivered O2 may be at 100%, the partial pressure of oxygen
necessary to deliver 100% SLE cannot be obtained (ex: 100% O2 @ 8,000 feet only
provides 75% O2. EXAMPLE: A patient receiving a fraction of inspired oxygen
(FiO2) of 30% while on the ground, who is flying at a cabin altitude of 8,000 feet,
requires the FiO2 increased to 40% to deliver the same partial pressure of oxygen as
the patient was receiving on the ground (SLE).
Desired % O2 SLE cannot be obtained at these altitudes.
8.4.5.6.1. Monitor pulse oximetry (O2 saturation) and titrate O2 up or down

accordingly or as ordered by the VFS.
8.4.5.6.2. These parameters are based on hemoglobin because hematocrit may be
decreased or elevated in dehydration or fluid overload.
8.4.5.6.3. If not contraindicated, push oral fluids to prevent dehydration.
8.4.5.7. Pulmonary hygiene measures.
8.4.5.7.1. Assist into sitting position (if not contraindicated); position on a backrest
(if available).
8.4.5.7.2. Turn, cough, and deep breathe every two hours, and note color, amount
and consistency of secretions (e.g., soot, blood streaks, and clots).
8.4.5.7.3. Incentive spirometry if available every one to two hours while awake.
8.4.5.7.4. Use a pillow for abdominal/thoracic splinting when coughing.
8.4.5.7.5. If breathing is ineffective or absent reference AHA or equivalent, TNCC if

available, and DHA/J7 Education and Training guidelines for actions.
8.4.6. Hyperventilation.
8.4.6.1. An abnormal increase in the rate and depth of breathing. Although unrelated in
cause, the symptoms of hyperventilation and hypoxia are similar and often result in
confusion and inappropriate corrective procedures. Contributing factors can be related to
psychological stress, medications, physiological changes, and stresses of flight.
8.4.6.2. Treatment for hyperventilation:
8.4.6.2.1. At altitude, the treatment of hyperventilation and hypoxia for the AE
patient is similar. Reference AE Clinical Protocol – Emergency Oxygen and
encourage deep breathing (reference Attachment 2, A2.1.1).
8.4.6.2.2. When a patient is hyperventilating from anxiety, putting on a mask to
administer oxygen may heighten anxiety.
8.4.6.2.3. Methods to reduce the patient’s respiratory rate include counting to five
slowly while exhaling, working with the patient to control inhalations and exhalations
to only 10 times a minute. Give the patient a watch with a second hand, or a cell
phone with a stopwatch, and instruct them to maintain a respiratory rate between 10
and 12 breaths per minute.
8.4.7. Hypercapnia:
8.4.7.1. Refers to increased amounts of CO2 in the blood. CO2 accumulates in the blood
due to poor alveolar ventilation. As the O2 in the blood is lowered, the CO2 is raised.
Altitude can exacerbate hypercapnia. The increased CO2 stimulates the respiratory center
in the brain stem. Elevated CO2 is a powerful vasodilator, producing both peripheral and
cranial vasodilatation. Any condition causing poor alveolar ventilation can result in
hypercapnia.
8.4.7.2. Signs/symptoms of hypercapnia: Headache, vertigo, hypertension. Late
symptoms include hypotension, coma, and cardiac failure.
8.4.7.3. Pathological states primarily producing hypercapnia:
8.4.7.3.1. Central nervous system. Pharmacological depression (barbiturates,
narcotics, alcohol, and tranquilizers), cerebrovascular accident, meningitis and
encephalitis, severe intracranial hypertension associated with trauma, and tumors.
8.4.7.3.2. Diseases of nerves and muscles: Guillain-Barre’ syndrome, muscular
dystrophy, myasthenia gravis, insecticide poisoning, tetanus, chronic progressive
polyneuropathy, diptheritic polyneuritis, iatrogenic hemidiaphragmatic paralysis from
indwelling interscalene pain catheters, and poliomyelitis.
8.4.7.3.3. Diseases of the chest wall: Flail chest and kyphoscoliosis.
8.4.7.3.4. Metabolic diseases: Severe hypothyroidism, starvation, obesity, and
electrolyte imbalance.
8.4.7.3.5. Pulmonary causes: Chronic obstructive pulmonary disease (emphysema
and chronic bronchitis); acute obstructive disease; severe asthmatic disease; acute
bronchiolitis; mechanical obstruction such as blood, water, pus, pulmonary edema,

massive parenchymal lung disease, restrictive disease of the pleura, severe pain or
diaphragmatic embarrassment after surgery, mechanical obstruction of large airways,
upper respiratory obstruction, abdominal compartment syndrome, and obstruction of
trachea or large bronchi.
8.4.8. Care/management of endotracheal tube and tracheostomy patients.
8.4.8.1. Care providers for patients requiring artificial airway management, carry extra
airways with them.
8.4.8.2. Attach an approved end-tidal CO2 monitoring device or an in-line CO2 indicator
to the endotracheal or tracheostomy tube.
8.4.8.3. The ERCC team may elect to fill endotracheal and tracheostomy tube cuffs with
air and then attach to a cuff pressure monitor to minimize tissue trauma and the
complications of re-intubation.
8.4.8.3.1. Cuff pressure is usually maintained between 15-20 cm, and is checked
preflight, at cruise and hourly, on descent, and prior to deplaning. Document cuff
pressures on patients’ medical record.
8.4.8.3.2. If an ERCC team is unavailable and an endotracheal or tracheostomy tube
cuff requires inflation for flight, ensure it is inflated with air. Use minimal occlusion
volume/minimal leak technique to permit adequate ventilation and avoid tissue
trauma. WARNING: Excessive pressure in the endotracheal or tracheostomy cuffs
may decrease blood flow to tissue causing airway damage, while under inflation may
permit air leak/ineffective ventilation and increased potential for aspiration of upper
airway secretions.
8.4.8.4. Tracheostomy patients may require humidification during AE.
8.4.9. Ventilator patients.
8.4.9.1. Only approved or waived ventilators are used for AE missions. AECMs are
responsible for ensuring the ventilator interfaces with aircraft systems and a dedicated
regulator/oxygen line is available to operate ventilators.
8.4.9.2. Assure adequate portable oxygen is available for all phases of transport
including enplaning and deplaning.
8.4.9.3. Set up for ventilated patients:
8.4.9.3.1. During transport, an emergency oxygen line for any vented patient is
attached to a personal bag valve mask (BVM.). The BVM is kept on the litter
(normally under/behind backrest) connected to the oxygen unless using the oxygen
line for an in-line respiratory treatment.
8.4.9.3.2. Cardiac monitor.
8.4.9.3.3. Pulse oximetry.
8.4.9.3.4. CO2 monitor.
8.4.9.4. General nursing care for ventilated patients.
8.4.9.4.1. Ventilator-associated pneumonia (VAP) is any pneumonia occurring in the

patient who is intubated or who was extubated within the past 48 hours. Follow the
current clinical practice guidelines to prevent and mitigate VAP.
8.4.9.4.2. VS at least q 2 hours.
8.4.9.4.3. Oral care q 2 hours.
8.4.9.4.4. Nasogastric/oral gastric (NG/OG) tube inserted.
8.4.9.4.5. Raise head-of-bed 30 degrees, unless contraindicated.
8.4.9.4.6. Soft wrist restraints in place to prevent extubation or inadvertent removal
of vital therapeutic devices.
8.4.9.4.6.1. Every 1-hour restraint assessment and circulation is documented.
8.4.9.4.6.2. Reevaluate the patient and ventilator settings at altitude, changes at
altitude may require ventilator-setting adjustments.
8.4.9.4.6.3. Positive end-expiratory pressure (PEEP) settings typically remain
constant at altitude.
8.4.9.4.7. Administer pain and sedation medication, as ordered, for patient comfort.
8.4.10. Chest tubes.
8.4.10.1. Chest tubes may be left in position for AE. Either a chest drainage unit with an
integral one-way valve (e.g., Atrium Express 4050) or a Heimlich ® valve will be in
place prior to patient transfer to the flight line. (T-0). The Heimlich valve may be utilized
with a chest drainage system without a one-way valve system. Glass chest tube drainage
bottles are not used in-flight. WARNING: Use of the Heimlich valve with the Atrium
Express could cause great risk to a patient during rapid decompression because the
Atrium Express has a built in Heimlich valve. The addition of another Heimlich valve
causes dangerous negative pressure in the thoracic cavity during a rapid decompression.
Do not obstruct the positive pressure relief valve. Note: Frequently check water seal
drainage systems, which use fluid to establish suction, to ensure evaporation/changes in
pressure does not reduce suction.
8.4.10.2. Chest drainage units listed in the current AE Equipment Compendium are
approved for use in-flight; ensure familiarity with conditions for use. Other drainage units
may be encountered in the AE system and may be acceptable if a one-way valve system
is present, conditions for use in accordance with manufacturer guidelines are followed,
and a waiver is obtained in accordance with AFMAN 10-2909 and AFMAN 11-2AEV3.
A JPSR worksheet or DD Form 2852 is completed on all equipment requiring a waiver.
8.4.10.3. Patients may be airlifted 24 hours after chest tube removal.
8.4.10.3.1. A chest X-ray, anterior/posterior and lateral, with interpretation, is
completed post chest tube removal and documented in the patient’s medical records.
8.4.10.3.2. Patients post-chest tube removal, requiring AE before or within 24 hours
are approved by the referring provider and the VFS.
8.4.10.3.3. Occlusive dressing is applied to the site where the chest tube was
removed.
8.4.10.4. Preflight/in-flight considerations and care for chest tube patients.
8.4.10.4.1. Patient assessment includes: assessing breath sounds, VS with pulse
oximetry, and inspection of the chest tube site to ensure intact dressing and
connections for any leaks or kinks. Assess tidaling in the chest drainage device. In a
patient with a pleural chest tube, tidaling is normal. Oscillations are more apparent
when suction is momentarily turned off. If there is no tidaling, consider 1) an
occlusion somewhere between the pleural cavity and the water seal, 2) a full
expansion of the lung where suction has drawn the lung up against the holes in the
chest tubes, or 3) PEEP, which can dampen oscillation. WARNING: Check chest
tubing for occlusion and assess patient for bilateral rise and fall of chest wall.
8.4.10.4.2. Ensure all connections are taped, tubing is not looped or kinked or
hanging below the drainage system.
8.4.10.4.3. Mark level of collection chamber and notify VFS if drainage is in excess
of 100ml since leaving the ERPS or MTF.
8.4.10.4.4. Document presence or absence of an air leak in the water seal (bubbling
indicates free air in the pleural cavity).
8.4.10.4.5. Do not allow the chest drainage system to be above the level of the chest.
8.4.10.4.6. Position patient mid-tier or above to facilitate drainage. Patients with
chest tubes are not be floor-loaded.
8.4.10.4.7. The chest tube is only clamped if directed by a privileged provider. If
directed by the privileged provider, a Kelly clamp accompanies the patient while in
the AE system.
8.4.10.4.8. Maintain and document I&O on each leg of the mission in the EHR or the
AF Form 3899E, Patient Movement Intake/Output, as required.
8.4.10.4.9. Check the suction control frequently and adjust the suction control to
maintain the appropriate amount of suction according to the physician’s order. If the
chest drainage system uses water to maintain suction, adjust suction control for
minimal bubbling according to manufacturer’s recommendations. Ensure patient is
utilizing an incentive spirometer (IS) and/or coughing and deep breathing every one
to two hours while in-flight.
8.4.10.4.10. Move and drain chest drainage tubing hourly to facilitate flow and
prevent clotting. WARNING: If clotting is suspected, do not milk or strip chest
tubes; this has the potential to causes increased intra-pleural pressure. If you see
visible clots, squeeze hand-over-hand along the tubing and release the tubing between
squeezes to help move the clots in the drainage unit.
8.4.10.4.11. Unless contraindicated, position on a backrest for comfort.
8.4.10.4.12. Pain medication as required.
8.4.11. Pulmonary emergencies.
8.4.11.1. Initial response to pulmonary emergencies.

8.4.11.1.1. Maintain the airway and assist breathing. Reference AHA or equivalent,
TNCC if available, and DHA/J7 Education and Training guidelines.
8.4.11.1.2. Administer high flow O2 to maintain pulse oximetry greater than 92% or
as directed by VFS.
8.4.11.1.3. Establish IV access.
8.4.11.1.4. The AECM notifies C2 who then contacts the governing PMRC for
guidance, possible cabin altitude restriction, and diversion to a MTF capable of
handling the situation, as required.
8.4.11.2. Asthma/COPD.
8.4.11.2.1. Assess signs and symptoms:
8.4.11.2.1.1. Tachypneic, labored respirations with increased effort on exhalation
(prolonged).
8.4.11.2.1.2. Possible cough and dyspnea.
8.4.11.2.1.3. Signs of hypoxia (reference Table 8.5).
8.4.11.2.1.4. The presence of wheezing, difficulty speaking, and use of accessory
muscles indicates an emergent situation.
8.4.11.2.2. Emergency treatment/management (reference AE Clinical Protocol -
Emergency Oxygen).
8.4.11.2.3. Administer medication and oxygen as directed.
8.4.11.2.3.1. The goal of oxygen administration for a COPD patient is to
maintain adequate arterial blood saturation with oxygen (SaO2) without
worsening acidosis. WARNING: Patients with chronically elevated blood CO2
levels may rely on relative hypoxia as a respiratory driver. Titrating O2 outside
ordered SpO2 parameters may result in decreased respiratory drive. In a clinical
emergency, high flow oxygen may be required. Patients receiving high flow O2
require full time observation.
8.4.11.2.3.2. Encourage oral (PO) fluids or consider IV maintenance fluids, if not
contraindicated.
8.4.12. Tension pneumothorax.
8.4.12.1. Air enters the pleural space and is unable to escape. This may occur as a result
of trauma, complication of medical treatment/procedure or spontaneously. Tension
pneumothorax may also be due to a kinked or clotted chest tube. The involved lung
collapses and the mediastinum shifts to the opposite side, compressing the contralateral
lung. Venous return to the heart is decreased and cardiac output is dramatically reduced.
8.4.12.2. Tension pneumothorax signs and symptoms:
8.4.12.2.1. Hypoxia (reference Table 8.5).
8.4.12.2.2. Severe respiratory distress with dyspnea (air hunger and rapid
respirations) and cyanosis.
8.4.12.2.3. Decreased or absent chest expansion on affected side.
8.4.12.2.4. Diminished or absent breath sounds on affected side.
8.4.12.2.5. Difficulty ventilating patient with endotracheal tube.
8.4.12.2.6. Presence of clots in the chest tube or Heimlich valve.
8.4.12.2.7. Hyper-resonance on percussion.
8.4.12.2.8. Subcutaneous emphysema.
8.4.12.2.9. Distended neck veins and hypotension.
8.4.12.2.10. Tracheal shift to unaffected side (late sign).
8.4.12.3. Tension pneumothorax treatment/management:
8.4.12.3.1. If this is assessed and not previously treated preflight, the patient is not
stable for flight.
8.4.12.3.2. If chest tube is present:
8.4.12.3.2.1. Assure the drainage system is operational.
8.4.12.3.2.2. WARNING : If clotting is suspected, do not milk or strip chest
tubes; this has the potential to causes increased intra-pleural pressure. If you see
visible clots, squeeze hand-over-hand along the tubing and release the tubing
between squeezes to help move the clots in the drainage unit.
8.4.12.3.3. If a chest tube is not present, patent, or operable, a needle decompression
(NDC) is performed immediately. The NDC is performed using the NDC kit or an
alternative 14 or 10-Gauge, 3.25-inch needle (reference AHA or equivalent, TNCC if
available).
8.4.12.3.3.1. Continue to assess patient. Decompression may have to be repeated
until a chest tube is inserted.
8.4.12.3.3.2. Decrease the cabin altitude, if operationally feasible.
8.4.12.3.3.3. The AECM notifies C2 who then contacts the governing PMRC for
guidance and possible diversion to a MTF capable of handling the situation.
8.4.12.3.3.4. Continue to closely monitor the pulse oximeter and patient for
recurrence.
8.4.13. Open pneumothorax. Air enters the chest via an open wound; also known as a
“sucking chest wound.”
8.4.13.1. Signs and symptoms:
8.4.13.1.1. Severe respiratory distress with dyspnea and cyanosis.
8.4.13.1.2. Gurgling, sucking wound.
8.4.13.1.3. Tachypnea and grunting.
8.4.13.2. Treatment/management:
8.4.13.2.1. Treat by applying an occlusive dressing completely over the defect during
expiration.
8.4.13.2.2. Allow the casualty to adopt the sitting position if breathing is more
comfortable.
8.4.13.2.3. Monitor for possible development of subsequent tension pneumothorax.
8.4.13.2.4. If signs of a tension pneumothorax develop, REMOVE the occlusive
dressing for a few seconds and allow the tension pneumothorax to decompress, then
replace. If this does not resolve the issue, reference paragraph 8.4.12.3
8.4.14. Massive hemothorax.
8.4.14.1. Signs and symptoms:
8.4.14.1.1. Severe respiratory distress with dyspnea.
8.4.14.1.2. Signs of shock (paragraph 8.8), hypoxia (paragraph 8.5) and reference
AE Clinical Protocol – Emergency Oxygen.
8.4.14.1.3. Breath sounds decreased or absent.
8.4.14.1.4. More than l00ml of blood loss per hour from chest tube.
8.4.14.1.5. Traumatic injury to the chest.
8.4.14.2. Treatment/management.
8.4.14.2.1. Seek immediate assistance from a privileged provider/C2/PMRC for
guidance and possible diversion to a MTF capable of handling the situation. Treat
shock as appropriate.
8.4.14.2.2. Chest tube placement is required.
8.4.15. Flail chest.
8.4.15.1. Multiple rib fractures resulting in loss of chest wall stability. Normal thoracic
function and gas exchange are impaired. The underlying pulmonary contusion and
splinting of the fracture pain leads to hypoventilation and hypoxia. The flailing segment
moves inward during inspirations and outward during expiration. Severe muscle spasms
may conceal the flailing segment.
8.4.15.2. Signs and symptoms.
8.4.15.2.1. Respiratory distress with dyspnea, cyanosis, and hypoxia.
8.4.15.2.2. Paradoxical chest wall movement.
8.4.15.2.3. History of blunt trauma to the chest.
8.4.15.3.1. Supplemental oxygen. Evaluate for elective intubation.
8.4.15.3.2. Adequate pain management (reference paragraph 8.21).
8.4.15.3.3. Position for comfort. Note: Place on affected side if in respiratory

distress to improve oxygenation of unaffected lung.
8.4.15.3.4. Monitor IVF infusion to avoid fluid overload.
8.4.15.3.5. Pulmonary failure may require emergent intubation.
8.4.15.3.6. May require PEEP or Continuous Positive Airway Pressure.
8.4.16. ARDS.
8.4.16.1. Lung injury with several causes and may be a complication of other diseases,
injuries, volume overload, infection, toxic inhalation, massive transfusion, etc.
8.4.16.2. ARDS results from a severe alteration in pulmonary vascular permeability,
which leads to a change in lung structure and fluid shift to interstitial space (edema).
Interferes with alveolar-capillary membrane affecting ventilation.
8.4.16.3.1. Supplemental oxygen/ventilator support.
8.4.16.3.2. PEEP (if required).
8.4.16.3.3. Monitor continuous pulse oximetry.
8.4.16.3.4. Fluids are restricted unless shock is present.
8.4.16.3.5. Turn patient every two hours unless contraindicated to promote postural
drainage.
8.5. Hypoxia.
8.5.1. Hypoxia is a general term describing an oxygen deficiency in the tissues sufficient
enough to cause impairment of function. Oxygen deficiency can result from various causes.
AE patients are already in a compromised state, are at a higher risk and may experience signs
of hypoxia faster than normal. Administer oxygen for any sign of hypoxia, respiratory
distress, or significant change from original assessment. Base the treatment on underlying
pathology, preflight VS and pulse oximetry.
8.5.2. Stages of altitude induced hypoxia.
8.5.2.1. Indifferent stage: Starts at sea level and extends to 10,000 ft. The body reacts
with a slight increase in heart rate and ventilation. Night vision begins to diminish at
5,000 ft.
8.5.2.2. Compensatory stage: Extends from 10,000 ft. to 15,000 ft. The body attempts to
protect itself against hypoxia by increasing BP, heart rate, and the rate and depth of
respiration. Efficiency and performance of tasks requiring mental alertness becomes
impaired.
8.5.2.3. Disturbance stage: Extends from 15,000 ft. to 20,000 ft. Characterized by
dizziness, sleepiness, tunnel vision, and cyanosis. Thinking becomes slowed and there is
a loss of muscle coordination.
8.5.2.4. Critical stage: Extends from 20,000 ft. to 30,000 ft. Marked mental confusion,
incapacitation followed by unconsciousness.
8.5.3. Major causes of hypoxia in the AE environment:

8.5.3.1. High altitude: Altitude is the most common cause of in-flight hypoxia.
8.5.3.2. Hypoventilation: Hypoventilation is inadequate ventilation often caused by
diseases outside the respiratory system and can exist when lung tissue is normal. Over-
sedation is a common cause of hypoventilation.
8.5.3.3. Lung pathology: Conditions of the lungs producing arterial hypoxia in the
presence of normal alveolar PaO2 is termed “increased alveolar-arterial oxygen tension
difference.” Three mechanisms contribute to this condition:
8.5.3.3.1. Diffusion defect: Interference with diffusion of oxygen from alveolar air
into pulmonary blood results in lowered PaO2. This is seen in diffuse pulmonary
infiltration, interstitial fibrosis, early edema, viral pneumonia, sarcoidosis, and
anemia.
8.5.3.3.2. Abnormal perfusion-ventilation ratio: An important aspect of normal lung
physiology is local/regional optimization of alveolar perfusion based on the
ventilation of the alveolar-capillary units. In certain lung diseases there is a
breakdown of this optimization with a resulting deterioration in gas exchange. This is
seen in patients with pulmonary emphysema, status asthmaticus, pulmonary edema,
pulmonary embolus, and chronic bronchitis.
8.5.3.3.3. Intrapulmonary shunts: When the ventilation/perfusion ratio is abnormal
due to poor ventilation of the alveoli, the blood passes through the involved parts of
the lung without the oxygen-carbon dioxide exchange occurring. For example, in
lobar pneumonia, the blood passes directly from the pulmonary arterial circulatory
system into the pulmonary venous system without a gas exchange.
8.5.4. Types of hypoxia:
8.5.4.1. Hypoxic hypoxia (altitude hypoxia): Caused by exposure to the airborne
environment. Results in deficiency in alveolar oxygen exchange. A lower barometric
pressure at altitude results in a decrease in alveolar PaO2 and interferes with ventilation
and perfusion. Any condition requiring oxygen at sea level is closely monitored at
altitude.
8.5.4.2. Altitude Blood Oxygen Saturation.
8.5.4.2.1. Sea level 98%.
8.5.4.2.2. 10,000 ft. 87%.
8.5.4.2.3. 22,000 ft. 60%.
8.5.4.3. Hypemic hypoxia: A reduction in the oxygen-carrying capacity of the blood
caused by anemia, hemorrhage, hemoglobin (Hgb) abnormalities (e.g., sickle cell
disease), medications (e.g., sulfanilamides, nitrites), or chemicals (e.g., cyanide, carbon
monoxide). WARNING: Carbon monoxide has a 200 x greater affinity to bond to Hgb
than oxygen. Pulse oximetry reading may not be accurate in carbon monoxide poisoning.
8.5.4.4. Histotoxic hypoxia: A deficiency of oxygen reaching the tissues due to

impairment of cellular respiration especially by a toxic agent such as alcohol. Histotoxic
hypoxia affects efficiency of cells to utilize oxygen, interfere with metabolic activity.
8.5.4.5. Stagnant hypoxia: A reduction in total cardiac output due to the pooling of
blood and the reduced blood flow to the tissues. Interferes with the transportation phase
of oxygen by reducing systemic blood flow. Causes include: Respiratory failure,
continuous positive pressure, ventilation, positive end expiratory pressure (PEEP),
cardiovascular and/or pulmonary embolus (blood clot or gas bubbles), shock, acceleration
(G-Forces), extremes in environmental temperature, postural changes, tourniquets,
arterial spasm, hyperventilation, and heart failure.
8.5.5. Characteristics of hypoxia:
8.5.5.1. Generally, patients are not familiar with their personal symptoms of hypoxia, so
AECMs are alert to all possible signs and symptoms patients may exhibit. Because AE
patients are already in a compromised state, they usually experience the effects of
hypoxia earlier than normal. Signs and symptoms are listed in Table 8.5
8.5.5.2. Cyanosis is a late sign of hypoxia because the oxygen saturation values are
below 75% in persons with normal Hgb before it is detectable.
Table 8.5. Signs and Symptoms of Hypoxia.

Signs Symptoms
Restlessness Confusion
Slouching Headache
Euphoria Dizziness
Confusion Euphoria
Stupor Blurred Vision
Dyspnea Tunnel Vision
Belligerence Insomnia
Tachypnea Hot and cold flashes
Hypertension Tingling
Tachycardia Numbness
Bradycardia Nausea
Arrhythmias Anger
Hypotension (late) Tachypnea
Cyanosis (late) Short of breath
Seizures (late) Changing judgment or
personality
Unconsciousness(late)
8.5.6. Due to the relative hypoxic environment in AE aircraft, patients having diagnoses or
conditions which compromise tissue oxygenation are considered for either oxygen
supplementation or a cabin altitude restriction, or both. The attending physician, in
consultation with the VFS, considers prescribing supplemental oxygen and/or cabin altitude
restriction and documents these orders in the patient movement request and the EHR or AF
Form 3899.
8.5.7. Prevent hypoxia by encouraging deep breathing and ambulation, if appropriate.
Evaluate potential causes of hypoxia: medications, underlying medical conditions, etc.
8.5.8. Treatment of hypoxia (reference AE Clinical Protocol – Emergency Oxygen).
8.5.8.1. Request lower cabin altitude if unresponsive to high flow O2 and operationally
feasible.
8.5.8.2. When administering O2 to correct hypoxia, allow approximately three to five
minutes to elapse for a more accurate pulse oximeter reading.
8.5.9. Documentation includes subjective and objective data for giving oxygen; VS, date,
time and delivery method of administering the oxygen (e.g., non-rebreather mask at 15 LPM
or nasal-cannula at 4 LPM), notification of a physician, and the outcome. The following
statement is documented on the EHR or AF Form 3899: “Oxygen was administered in
accordance with AE Clinical Protocol – Emergency Oxygen”. Completion of a JPSR
worksheet or DD Form 2852 is also required.
8.6. Pulmonary Embolism (PE)/VTE Events During AE.
8.6.1. PE is the obstruction of one or more pulmonary arteries by a thrombus usually
originating in the deep veins of the legs. VTE occurs when a blood clot forms in a person’s
veins.
8.6.2. Stresses of flight contributing to PE/VTE events.
8.6.2.1. Thermal: Excessive heat leads to additional dehydration.
8.6.2.2. Decreased humidity: Leads to dehydration. Dehydration effects the flow of
venous blood volume and may cause additional stasis.
8.6.2.3. Fatigue: Excessive fatigue may cause patients to be static for longer periods of
time. They may not have the energy to walk or complete the recommended movements or
exercises.
8.6.2.4. G-forces: May cause additional venous stasis, leading to pooling of the blood.
8.6.2.5. Flights lasting longer than four hours compound the other stresses of flight.
8.6.3. Higher risk for PE/VTE includes patients with: Prolonged bed rest, long bone or
pelvic trauma, obesity, history of smoking, history of thromboembolic disease, varicose
veins, pregnancy, post-partum, history or family history of PE/VTE, estrogen use, heart
failure, myocardial infarction, active cancer, recent surgery, leg cast or splint and/or over the
age of 40.
8.6.4. PE signs and symptoms.
8.6.4.1. Dyspnea, pleuritic chest pain, wheezing, crackles on auscultation, restlessness,
and hemoptysis. Note: In-flight auscultation is not a reliable assessment tool.
8.6.4.2. Elevate the head of bed, with a backrest if available; get a full set of VS and
place on oxygen in accordance with AE Clinical Protocol – Emergency Oxygen.
8.6.4.3. The AECM notifies C2 who then contacts the governing PMRC for guidance.
8.6.5. VTE signs and symptoms:

8.6.5.1. Pain in the calf or behind the knee that may increase with standing or
ambulating, the feeling of being on pins and needles, swelling (especially unilateral), skin
that is warm to touch, erythema, and a systemic temperature greater than 100.4F. Many
VTEs are asymptomatic.
8.6.5.2. Homan’s sign is often unreliable due to false positives. It is no longer
recommended.
8.6.5.3. VTE prophylaxis is essential to preventing complications of immobility in the
AE system. Prophylactic methods or measures may include:
8.6.5.3.1. Frequent ambulation, if possible, as well as stretching and flexing of calf
muscles. Adequate hydration and frequent changes in position are required
throughout the AE system.
8.6.5.3.2. Sequential Compression Devices (SCD) or foot pumps provide non-
pharmacologic VTE prophylaxis in critical care and immobilized patients. Some
patients being transported benefit from use of a combination of non-pharmacologic
and pharmacologic VTE prophylaxis. Approved SCDs in the AE environment may be
used on one or more extremities and provides improved benefit over no mechanical
prophylaxis.
8.6.5.3.3. VFS may consider blood-thinning or clot preventing medications (e.g.,
heparin, low molecular weight heparins (Lovenox), or Coumadin).
8.7. Cardiovascular Management.
8.7.1. Stresses of flight affecting the cardiovascular system.
8.7.1.1. Decreased partial pressure of oxygen: Increases myocardial workload,
predisposing compromised patients to arrhythmias, chest pain and may lead to
myocardial infarction. Consider cabin altitude less than 6,000 ft. for cardiac patients.
8.7.1.2. Barometric pressure changes: Gas expansion in the GI tract may cause
diaphragmatic crowding and decrease in tidal volume.
8.7.1.3. Thermal: Excessive heat may cause patients on cardiac medication to become
hypotensive. Hyperthermia and hypothermia may increase cardiac oxygen requirements.
8.7.1.4. Fatigue: Cumulative effect of stresses may exacerbate the patient’s condition.
8.7.1.5. G-forces: Ascent may increase returning blood flow and cardiac workload for
some cardiac patients. Use a backrest for cardiac patients on a litter.
8.7.2. Preflight/in-flight considerations for cardiac patients.
8.7.2.1. Use alternate anti-hijacking procedures for patients and passengers with
implantable cardiac pacemakers and defibrillators. WARNING: EMI from handheld and
stationary surveillance systems interferes with these medical devices. Changes in pacing
rates, shock, and possible cardiac arrest may occur.
8.7.2.2. Patients with a recent acute myocardial infarction are considered for AE on an
individual basis. The referring privileged provider and VFS work together to determine
the appropriate AE precedence and clinical support for cardiac patients. When continuous
cardiac monitoring or other critical care modalities are required, the VFS, in consultation
with the referring privileged provider, determines if an ERCC team or MA such as a
physician or ACLS trained nurse is required to accompany the patient. The final decision
for determining these requirements rests with the VFS. A 12-Lead electrocardiogram
taken within 24 hours of scheduled flight and read by a qualified physician accompanies
the patient.
8.7.2.3. Patient history.
8.7.2.3.1. Assess if patient is free of chest pain. Document the last episode and if it
was associated with dyspnea, nausea and/or diaphoresis. Note what
actions/medications were used to relieve pain/discomfort. List other current
medications, allergies, and presence of pacemaker or other implantable cardioverter-
defibrillator.
8.7.2.3.2. Assess ability to ambulate for prolonged periods and climb stairs.
8.7.2.3.3. All inpatient cardiac patients require preflight VS and pulse oximetry,
repeat VS and pulse oximetry at altitude.
8.7.2.3.4. If the patient has nitroglycerin, ensure it is not expired and the patient
notifies the AECM if consumed.
8.7.2.4. Use a backrest if on litter.
8.7.2.5. Place near O2 for flight.
8.7.2.6. The cardiac monitor, if ordered, is placed in a viewable position for an ACLS
certified member in all phases of transport when feasible.
8.7.3. Cardiac emergencies/cardiac arrest: ERCC team/MA may be included in the medical
emergency procedures if clinically qualified to assist. For defibrillation procedures reference
current TNCC if available and current AHA or equivalent and DHA/J7 Education and
Training guidelines on practices and assessment skills and AFMAN 11-2AEV3. The AECM
notifies C2 who then contacts the governing PMRC. Complete a JPSR worksheet or DD
Form 2852 for change of status.
8.7.4. Ischemic chest pain (reference AHA or equivalent, TNCC if available, and DHA/J7
Education and Training guidelines).
8.7.5. Congestive heart failure/cardiogenic shock: Heart failure may result from a
myocardial infarction (MI), valvular malfunction, septal defect, left ventricular aneurysm or
cardiac trauma.
8.7.5.1. Assess cardiopulmonary, neurological, and hemodynamic status of BP, heart
rate, pulse oximetry, GCS, peripheral perfusion, presence of edema, color and warmth of
skin.
8.7.5.2. Signs and symptoms: Anxiety, dyspnea/shortness of breath with rales and
rhonchi, distended neck veins, tachycardia, hypertension, or hypotension (cardiogenic
shock), diaphoresis, arrhythmias. Appears ashen with cool and clammy skin.
8.7.5.3. Treatment/Management: If symptoms develop during flight, the AECM notifies

C2 who then contacts the governing PMRC for guidance (reference Lippincott or
Mosby).
8.7.6. Cardiac tamponade. Rapid or slow accumulation of fluid into pericardial sac
compresses the heart and decreases cardiac output. Results from inflammation, traumatic
wound injury to heart, heart failure, cardiac contusion, neoplasm, and aortic dissection.
8.7.6.1. Assess signs and symptoms: Beck’s Triad: (distended neck veins, low arterial
pressure and distant/muffled heart sounds), dyspnea, tachypnea, cyanosis, tachycardia,
hypotension, and severe anxiety. QRS may have smaller amplitude. Note: Recommend
use of ultrasound to diagnose cardiac tamponade if available.
8.7.6.2. Treatment/Management of Cardiac Tamponade:
8.7.6.2.1. Reference AHA or equivalent, TNCC if available, and DHA/J7 Education
and Training guidelines.
8.7.6.2.2. Avoid positive pressure ventilation via bag-mask or endotracheal tube. The
physician may order a fluid challenge. The only treatment alleviating the cause is
pericardiocentesis. WARNING: Only a healthcare professional who has the scope of
practice to accomplish a pericardiocentesis perform this procedure.
8.7.7. Symptomatic premature ventricular contractions, tachycardia, and cardiac arrest.
Reference AHA or equivalent, TNCC if available, and DHA/J7 Education and Training
guidelines.
8.7.8. Treatment and Management of Symptomatic bradycardia. Reference Transcutaneous
Pacing (TCP) in AHA or equivalent, TNCC if available, and DHA/J7 Education and
Training guidelines.
8.7.8.1. Contact C2 for mission diversion and VFS guidance on sedation and pain
medication prior to starting TCP if patient is stable. AETs (operating within their SOP)
may assist with set up but may not initiate TCP.
8.7.8.2. TCP is used for short intervals until transvenous pacing can be initiated.
8.7.9. Treatment and Management of Ventricular fibrillation/ventricular tachycardia.
Reference AHA or equivalent, TNCC if available, and DHA/J7 Education and Training
guidelines and AFMAN 11-2AEV3 and AE Medical Equipment Compendium for
information specific to defibrillation on an aircraft.
8.7.10. Treatment and Management of Asystole and Pulseless Electrical Activity. Reference
AHA or equivalent, TNCC if available, and DHA/J7 Education and Training guidelines.
8.8. Shock Management.
8.8.1. Stresses of flight affecting shock.
8.8.1.1. Decreased partial pressure: As altitude increases, ambient air pressure
decreases, leading to a decrease in the oxygen tension which results in a decreased PaO2.
8.8.1.2. Thermal: Inadequate peripheral perfusion aggravated by the potential
temperature extremes.
8.8.1.3. Humidity: The humidity in aircraft cabins is extremely low and exacerbates
fluid loss.
8.8.1.4. Fatigue: Can exacerbate the patient’s underlying condition/diagnosis due to the
overall effect of stresses of flight and length of time the patient has been in the AE
system. Disruption of circadian rhythms occurs when crossing multiple time zones.
8.8.2. General: Shock is a physiologic state characterized by a significant reduction of
systemic tissue perfusion, resulting in decreased oxygen delivery to the tissues. This creates
an imbalance between oxygen delivery and oxygen consumption. Prolonged oxygen
deprivation leads to cellular hypoxia and derangement of critical biochemical processes at the
cellular level, which can progress to the systemic level.
8.8.3. Types of shock.
8.8.3.1. Hypovolemic shock is a lack of oxygen to the tissues caused by reduced blood
volume.
8.8.3.1.1. Hypovolemic shock may result from hemorrhage-induced blunt or
penetrating trauma, GI bleeding, hemorrhagic pancreatitis, fractures, ruptured aorta,
abdominal or left ventricular free wall aneurysm.
8.8.3.1.2. Also caused by fluid loss induced by diarrhea, vomiting, heat stroke,
inadequate repletion of insensible losses, burns, and third spacing.
8.8.3.1.3. Treatment of hypovolemic shock. Reference AHA or equivalent, TNCC if
available, and DHA/J7 Education and Training guidelines.
8.8.3.2. Cardiogenic shock is a lack of oxygen to the tissues caused by cardiac pump
failure or pulmonary embolism.
8.8.3.2.1. Specific conditions/events lead to cardiogenic shock including myocardial
infarction involving greater than 40 percent of the left ventricular myocardium, right
ventricular infarction, dilated cardiomyopathies, stunned myocardium following
prolonged ischemia, cardiopulmonary bypass, myocarditis and both atrial and
ventricular arrhythmias.
8.8.3.2.2. Atrial fibrillation and flutter reduce cardiac output. Mechanical causes of
cardiogenic shock include valvular defects, ventricular septal defects, or rupture,
atrial myxomas and a ruptured ventricular free aneurysm. Other cardiac causes of
cardiogenic shock include massive pulmonary embolism, tension pneumothorax,
severe constrictive pericarditis, and pericardial tamponade.
8.8.3.2.3. Treatment of cardiogenic shock.
8.8.3.2.3.1. Attempt to determine the cause of cardiogenic shock: Myocardial
infarction, myocardial depression due to advanced septic shock, atrial or
ventricular arrhythmia, Brady arrhythmia, pulmonary embolism, tension
pneumothorax, constrictive pericarditis, pericardial tamponade and severe
pulmonary hypertension.
8.8.3.2.3.2. Perform fluid resuscitation to correct hypovolemia and hypotension
unless pulmonary edema is present.
8.8.3.2.3.3. Additional drug therapy may be necessary as determined by a

privileged provider.
8.8.3.3. Distributive (vasodilatory) shock is a lack of oxygen to the tissues caused by
hypotension due to an infection or anaphylactic reaction. Examples include neurogenic,
septic, and anaphylactic.
8.8.3.3.1. May result from systemic inflammatory response, pancreatitis, burns or
multiple traumatic injuries. Also, from toxic shock syndrome, anaphylaxis and
anaphylactoid reactions, drug or toxin reactions including insect bites, transfusion
reactions, and heavy metal poisoning.
8.8.3.3.2. Other contributing factors include Addisonian crisis, myxedema coma,
neurogenic shock after spinal cord injury, acute systemic inflammation following
acute myocardial infarction, post-resuscitation syndrome and post-cardiopulmonary
bypass.
8.8.3.3.3. Treatment for distributive shock.
8.8.3.3.3.1. Evaluate for decreased peripheral perfusion as indicated by delayed
capillary refill and cool mottled extremities, dry skin, dry oral mucosa, or postural
hypotension.
8.8.3.3.3.2. At least one to two liters of NS or Lactated Ringers are initially given
as rapidly as possible in an attempt to restore tissue perfusion.
8.8.3.3.3.3. Continue fluid resuscitation at the initial rapid rate as long as the
systemic BP remains less than 90mm Hg. Monitor fluid intake/urine output
(UOP), BP, mental status, and peripheral perfusion.
8.8.3.3.3.4. If it is neurogenic shock, restore volume. Do not use vasoactive
medications until volume is restored. Steroids are only be used after consultation
with a neurosurgeon. Keep the patient as normo-thermic as possible.
8.8.3.3.3.5. If it is septic shock, treat the underlying infection. Antibiotics and
fluid bolus in accordance with physician’s orders.
8.8.3.3.3.6. If it is anaphylactic shock, initiate resuscitation and follow the AE
Clinical Protocol - Anaphylactic Reaction.
8.8.3.4. Obstructive Shock.
8.8.3.4.1. Obstructive Shock may result from circulatory compromise due to direct
failure of the heart muscle or compression or obstruction of blood flow through the
heart or great vessels.
8.8.3.4.2. Contributing factors include cardiac tamponade, tension pneumothorax,
and pulmonary embolism.
8.8.3.4.3. Signs and symptoms include apprehension, shortness of breath, tracheal
deviation, jugular vein distention.
8.8.3.4.4. Treat the underlying pathology.
8.8.3.5. The different types of shock can coexist. As an example, patients with septic
shock often have a hypovolemic component, a cardiogenic component (due to sepsis-
related dysfunction), and a distributive component (due to the effects of inflammatory
and anti-inflammatory cascades on vascular permeability and vasodilatation).
8.8.4. Clinical presentation of shock varies according to the type of shock, its cause, and its
stage of presentation.
8.8.4.1. Early signs of shock are characterized by rapid compensation for the diminished
tissue perfusion. The early symptoms may include anxiety, restlessness, tachycardia, pale
clammy skin, and either a modest increase or decrease in systemic BP.
8.8.4.2. As compensatory mechanisms become overwhelmed, additional symptoms for
late shock may include diaphoresis, decreased urine output, agitation, lethargy, dizziness,
hypotension, obtunded, and coma.
8.8.5. Treatment/management and preflight/in-flight considerations for shock.
8.8.5.1. Control hemorrhage and maintain circulation, airway, and breathing (reference
AHA or equivalent, TNCC if available, and DHA/J7 Education and Training guidelines).
8.8.5.2. Correct hypoxemia. Open airway with adjuncts if necessary. Maintain ventilator
support if appropriate. Provide supplemental oxygen with high flow delivery (reference
AE Clinical Protocol –Emergency Oxygen).
8.8.5.3. Place the patient in supine position to assist with perfusion. Keep the patient
warm.
8.8.5.4. Establish two large bore IV’s if not already in place.
8.8.5.5. Monitor BP as needed but at a minimum hourly.
8.8.5.6. UOP goal is 30-50 ml/hour.
8.9. Burn Management.
8.9.1. Burn patients are frequently transported on AE missions and require intensive in-flight
nursing care. The expert burn management consultants for worldwide AE are at the United
States Army Institute for Surgical Research (USAISR). C2 and PMRC coordinates the
delivery of the burn team and their equipment to the originating facility and subsequent AE
airlift of the patient back to the burn center. In many cases, an ERCC team may accompany
the burn patient to the ISR or to a civilian burn center. The PMRC and VFS refers to the JTS
Burn Care CPG for burn care recommendations.
8.9.2. Stresses of flight affecting burn patients.
8.9.2.1. Decreased partial pressure of oxygen: Exacerbates oxygenation deficiencies due
to compromised respiration and/or the decreased partial pressure of oxygen in the
presence of any inhalation injury or ARDS.
8.9.2.2. Barometric pressure changes include increased gastric distention and discomfort.
8.9.2.3. Humidity: Exacerbates fluid loss.
8.9.2.4. Vibration: May increase pain.
8.9.2.5. Thermal: Loss of natural insulation and skin integrity leaves the patient prone to
hypothermia. Severity of the burn affects the autonomic temperature regulatory functions.
8.9.2.6. Fatigue: Exacerbates the patient’s underlying condition.
8.9.3. Intra-theater triggers to activate burn flight team. Patients with significant burns, as
defined by ABA criteria (http://www.ameriburn.org), benefit from prompt consultation
with a burn surgeon and transport to a burn center (reference Attachment 10).
8.9.3.1. The treating physician initiates the PM process and contacts USAISR Burn
Center designated representative. Governing PMRC assists the sending physician with
appropriate recommendations for PM process. Physician-to-physician communication is
vital in developing optimal movement plan for each patient. The USAISR Burn Center
can be contacted at 210-222-2876 or DSN 312-429-2876.
8.9.3.2. Burn patients are validated for movement precedence in consultation with the
VFS, USAISR Burn Center and referring privileged provider. If TRAC2ES is not
available, direct contact with servicing PMRC is recommended to facilitate PM. The
USAISR Burn Center provides the name of accepting burn surgeon. Delay or inability to
contact the USAISR Burn Center directly does not delay processing of the PMR.
8.9.4. Burns: Preflight/in-flight considerations.
8.9.4.1. Airway: Anticipate possible airway/trachea edema. If clinically indicated,
secure airway early with the largest endotracheal tube possible prior to transport.
8.9.4.1.1. Signs and symptoms of inhalation injury. Note: Inhalation injuries are at
high risk for rapid airway obstruction.
8.9.4.1.1.1. Nasal/mucosal charring, burns and/or soot on face, in mouth and
nose, carbonaceous sputum, and hoarseness.
8.9.4.1.1.2. Carbon monoxide poisoning symptoms include pink to cherry-red
skin, tachycardia, tachypnea, headache, dizziness, and nausea; central nervous
system (CNS) symptoms vary with carboxyhemoglobin level. WARNING: Pulse
oximetry reading is not accurate in carbon monoxide poisoning.
8.9.4.1.2. Evaluate individuals involved in blasts and/or confined in a burning
environment for airway compromise. Note: Onset may be delayed, and other injuries
may not be apparent.
8.9.4.1.3. Secure tubes with ties or suture rather than tape. Tape does not secure well
on burned skin and increases risk of endotracheal tube dislodgement. Important to
reassess endotracheal tube placement every hour for the first 24-48 hours as edema
forms and resolves.
8.9.4.1.4. If non-vented, administer high flow O2 via humidifier bottles in-flight to
provide cool mist and maintain pulse oximetry greater than 92% or as directed by
VFS.
8.9.4.1.5. Patients with known or suspected inhalation injury may require specialized
mechanical ventilation.
8.9.4.2. For patients with burns 20% TBSA or more, excluding first-degree burns,
consider placing an IV, NG/OG tube, and foley catheter for all phases of AE.
8.9.5. Burns: Fluid loss and IVF resuscitation.
8.9.5.1. IV access via two large bore (18 gauge or larger), if needed. Consider central
venous access if the patient undergoes fluid resuscitation prior to transport.
8.9.5.2. First 24 Hours:
8.9.5.2.1. IVF resuscitation is performed for patients whose burn size is greater than
or equal to 20% TBSA. Lactated Ringers (LR) is the preferred fluid for resuscitation.
The goal of initial fluid resuscitation is to restore and maintain adequate tissue
perfusion and vital organ function, in addition to preserving heat-injured but viable
tissue. Fluid needs are based on the size of the patient and the extent of the burn.
8.9.5.2.2. The ‘Rule of 10s’ offers a simplified method of estimating initial fluid rate
for thermal injuries and provides values generally between those calculated by the
Modified Brooke Formula and Parkland formula. The Rule of 10s is as follows:
Initiate fluid resuscitation using the Rule of 10s (10 mL/hour x % TBSA) for patients.
The Rule of 10s is applied for patients weighing between 40 and 80 kilograms (kg).
For patients weighing more than 80 kg, add 100 ml/hour to LR rate for each 10 kg
>80 kg.
8.9.5.2.3. Clinical indicators for adequacy of fluid resuscitation are: Clear
sensorium, heart rate < or equal to 120/minute (min), Mean Arterial Pressure (MAP)
> or equal to 55 mmHg, strong peripheral pulses, serum and electrolytes within
normal limits and the absence of metabolic acidosis.
8.9.5.3. Urinary output: Determines the adequacy of renal perfusion and fluid
resuscitation.
8.9.5.3.1. The primary target for resuscitation is to maintain adequate UOP of 30-50
ml/hr in adults. Titrate fluid up or down approximately 20% every hour to achieve
this goal. Document on the "Burn Flow Sheet" hourly. Note: Over resuscitation
may cause more harm than periods of under-resuscitation. Examples of such harm are
abdominal and extremity compartment syndromes. Thus UOP < 30 ml/hr is tolerated
if crystalloid infusion rates are persistently high (>1L/hr) and adjuncts to crystalloid
infusion are unsuccessful (e.g., colloid infusion).
8.9.5.3.2. With electrical burns, urine may be rusty red in color, indicating
myoglobinuria. If this occurs, then maintain an output of 75-100 ml/hour.
8.9.5.3.3. In children less than 30 kg, hourly UOP is maintained at 1ml/kg/hour.
8.9.6. Burn dressings:
8.9.6.1. Ensure burns are dressed with clean, dry, non-constrictive, bulky dressings.
Normally, dressings are not changed in-flight. Common dressings applied are:
8.9.6.1.1. Silverlon - Used on partial thickness to full thickness burns. This is a
synthetic non-adherent dressing impregnated with silver that is applied to an open
wound to prevent infection. This is moistened with sterile water prior to application to
activate the silver properties. Dressings are moistened with sterile water every 6 hours
to keep moist.
8.9.6.1.2. Sulfamylon 5% solution - Used on partial thickness to full thickness burns.
It prevents infection from gram negative and gram-positive bacteria. May cause pain
upon application to partial thickness burns. This dressing also requires wet downs
with the Sulfamylon 5% solution every 6 hours.
8.9.6.1.3. Bacitracin - Limited antimicrobial properties but easy to apply. Used for
superficial burns.
8.9.6.1.4. Silver dressings are preferred for long range transport to minimize dressing
changes.
8.9.6.2. Patient may see negative pressure wound dressings.
8.9.7. Cardiac monitoring: For patients with cardiac history, hypertension, electrical burns,
and patients over 50 years of age.
8.9.8. Circulation checks: All extremities. Monitor peripheral pulses Q1hr for electrical,
circumferential burns and those burns >20% TBSA. May require Doppler (difficult to hear
on aircraft) and may have escharotomy or fasciotomy. If the pulse is undetectable, the AECM
notifies C2 who then contacts the governing PMRC.
8.9.9. Mental status: Key indicator of hypoxia and cardiovascular stability. Perform
neurological assessments frequently.
8.9.10. Temperature control: Patients with extensive burns are extremely prone to
hypothermia. Monitor temperature and maintain a high temperature in the cabin, if possible.
The AECM can speak with the PIC and or the Loadmaster/Boom Operator whenever patients
are on board and the ambient temperature exceeds a comfortable level. Note: May cover
patient with first aid thermal blanket (e.g., space blanket), clean blankets or sleeping bags for
temperature control.
8.9.11. Positioning and exercise.
8.9.11.1. Essential to promote circulation and provide comfort. Prevents contractures,
pressure sores, thrombosis, and conversion of burns.
8.9.11.2. Maintain the position of function (e.g., hands, joints, and feet).
8.9.11.2.1. Elevate upper torso: Assists cerebral venous return, slows down edema
formation, and assists respiratory functions by offloading the diaphragm.
8.9.11.2.2. Elevate burned extremities: Reduces edema, increases venous return, and
reduces pain.
8.9.11.3. Consider pain medication prior to ROM exercise or changing positions.
8.9.11.4. Perform ROM exercises according to provider’s orders.
8.9.12. Narcotics/analgesics.
8.9.12.1. Used for both sedation and pain relief. Administered as ordered by the
physician. Do not give supplemental acetaminophen (Tylenol) with oral narcotics
containing acetaminophen (e.g., Percocet) as this may lead to toxicity risks.
8.9.12.2. Consider using continuous IV pain medication and sedation during transport.
8.9.12.3. IV pain medications may be administered by the AECM in accordance with the
AE Clinical Protocol - Pain Management.
8.9.13. The Burn Flight Team may internally feed critically ill patients during flight if
previous tube feedings were established. Patient may have an NG/OG tube inserted prior to
flight for medication administration and possible gastric decompression.
8.9.14. Eye drops/ointment/lacri-lube/antibiotics are frequently given to these patients.
8.10. Hematological and Endocrine Management.
8.10.1. Blood dyscrasia. Affects one or more of the blood components, the bone marrow, or
the entire blood system. It can be acute or chronic, acquired, or congenital. Seen in
chemotherapy, post-transplant, post-trauma, renal and liver disease.
8.10.2. Stresses of flight affecting patients with hematological disorders.
8.10.2.1. Decreased partial pressure of oxygen: Exacerbates the body’s decreased
oxygen transport capability in the blood leading to hypoxia and cardiac decompensation.
8.10.2.2. Thermal: Hot and cold temperatures increase the body’s oxygen requirements.
8.10.2.3. Decreased humidity: Dehydration causes headaches and decreases blood
volume.
8.10.2.4. Fatigue: Complicates the underlying pathology.
8.10.3. Red blood cells (RBCs): The efficiency of RBCs depends on the quantity and
quality of the hemoglobin it contains. Normal Hgb concentration is 14-16 grams (g)/deciliter
(dL) and varies with the patient’s gender and age.
8.10.3.1. Patients with Hgb below 8.0 mg may be transported if the condition is chronic
and stable, and not related to bleeding. Patients with a hematocrit (HCT) below 25% are
not airlifted without concurrence of the VFS. Low flow O2 is used continuously on
patients with extremely low Hgb or HCT levels, as in dialysis and chemotherapy patients.
A cabin altitude restriction below 5,000 ft. may be ordered by the VFS (reference Table
8.2).
8.10.3.2. Types of anemia.
8.10.3.2.1. Hemolytic: Destruction of erythrocytes caused by bacteria, parasites,
venom, transfusions, chemicals, and genetics (thalassemia and sickle cell). Sickle cell
crisis can occur at cabin altitudes as low as 4000 ft.
8.10.3.2.2. Aplastic: Failure of the bone marrow to produce erythrocytes due to
chemicals, medications, and disease.
8.10.4. White blood cells (WBCs or leukocytes): The main function of leukocytes is to
isolate areas of inflammation or infection.
8.10.4.1. Normal adult blood contains 5,000 - 10,000 WBC’s per cubic millimeter of
whole blood.
8.10.4.2. Leukocyte disorders. Caused by abnormal WBCs (too few, too many or
abnormal morphology).
8.10.4.2.1. Monitor preflight absolute neutrophil count (ANC) and en route

temperature. ANC below 1,000 is considered neutropenic and at risk for infection;
below 500 is a severe risk for infection and for flight. Monitor temperature every four
hours Temperature above 100.4 F is considered significant; above 101.0 F requires
communication. The AECM notifies C2 who then contacts the governing PMRC.
8.10.4.2.2. Use good hand washing, protective isolation with the patient wearing a
N95 or surgical mask.
8.10.4.2.3. Dietary considerations:
8.10.4.2.3.1. Avoid all fresh/uncooked fruits, nuts, and vegetables, including all
fresh garnishes, raw or rare-cooked meat, fish, and eggs. All eggs are thoroughly
cooked. Avoid yogurt and yogurt products with live and active cultures.
8.10.4.2.3.2. All canned, bottled, and powdered beverages and sports drinks are
OK. Brewed coffee and tea are acceptable.
8.10.5. Platelets (thrombocytes).
8.10.5.1. Normal platelet count is greater than 150,000/cubic millimeter.
8.10.5.2. Thrombocytopenia: Observe for bruising, uncontrolled bleeding, petechiae,
hematuria, hematomas, and GI bleeding. Avoid aspirin and other platelet inhibiting
medications.
8.10.6. Preflight/in-flight nursing care for blood dyscrasias.
8.10.6.1. Oxygen administration as needed (reference AE Clinical Protocol – Emergency
Oxygen). Note: These parameters are based on Hgb because HCT may be decreased or
elevated in dehydration or fluid overload.
8.10.6.2. Litter with backrest.
8.10.6.3. Offer blankets; patients with anemia tend to have a greater sensitivity to cold.
8.10.6.4. Offer fluids often to avoid headaches and decreased blood volume.
8.10.6.5. Administer blood products, as ordered. AF Form 1225, Informed Consent for
Blood Transfusion, signed if feasible.
8.10.6.6. Use standard and transmission-based precautions.
8.10.7. Diabetes Mellitus (DM). A condition in which the pancreas no longer produces
enough insulin, or cells stop responding to the insulin produced, thus presenting glucose in
the blood from absorbing into the cells of the body. Symptoms include frequent urination,
excessive thirst, hunger, and lethargy.
8.10.7.1. Stresses of flight affecting patients with DM, hypoglycemia, and
hyperglycemia.
8.10.7.1.1. Decreased partial pressure of oxygen: Diabetic retinopathy and
peripheral vascular symptoms may be exacerbated.
8.10.7.1.2. Decreased humidity: Leads to dehydration.
8.10.7.1.3. Thermal: May contribute to poor circulation, exacerbating sensitivity.
8.10.7.1.4. Fatigue: May precipitate/exacerbate condition.

8.10.7.2. Preflight/in-flight considerations for DM.
8.10.7.2.1. Assess patient’s knowledge of condition, symptoms, treatment, and
dietary restrictions.
8.10.7.2.2. Determine time of last meal.
8.10.7.2.3. Type, time, and amount of hypoglycemic medication.
8.10.7.2.4. Assure medications and special diets are onboard and available.
8.10.7.2.5. Ensure meals and snacks are served on time.
8.10.7.2.6. There is no glucose monitor or chemical strips in the AE allowance
standard. ERCC team may be able to assist with a glucose assessment in an
emergency situation using approved equipment. Although glucose monitors are not
included in the AE allowance standard, use of a glucose monitor approved for in-
flight use is authorized.
8.10.7.2.7. MTFs at RON destinations provides patient education and approved AE
glucose monitors. MTF’s test approved glucose monitors prior to flight to ensure
operation.
8.10.7.2.8. Blood glucose is checked prior to departure and/or at en route stops. If
glucose monitoring may be required ensure an approved glucose monitor
accompanies the patient in-flight. AECMs are prepared to assist patients and/or
attendants in performing blood glucose.
8.10.7.2.9. If a patient presents with objective and/or subjective signs of
hyperglycemia or hypoglycemia, assist the patient with obtaining a blood glucose
reading, contact the PMRC, and take additional action as required.
8.10.7.3. Hyperglycemia. Hyperglycemia is defined as an abnormally high blood
glucose level. Early symptoms of hyperglycemia include: Polydipsia, polyuria, fatigue,
blurred vision, headache, and dry warm flushed skin.
8.10.7.3.1. Late symptoms of hyperglycemia include sweet breath, hypotension,
nausea and vomiting, abdominal pain, dry mouth, weakness, shortness of breath,
confusion, Kussmaul respiration and coma.
8.10.7.3.2. Treatment/management. Insulin, fluids, electrolyte replacement as
directed by a privileged provider.
8.10.7.4. Hypoglycemia. Hypoglycemia is defined as a sub-therapeutic plasma glucose
concentration exposing an individual to harm. The American Diabetes Association and
the Endocrine Society Workgroup on Hypoglycemia published a clinical classification
system for hypoglycemia in patients with diabetes mellitus. This classification system
includes documented symptomatic hypoglycemic events and severe hypoglycemic
events. The low-normal cut-off value for a diabetic’s self-monitored blood glucose
(SMBG) level has been debated; with the low normal value ranging from <63 mg/dl to <
70mg/dl. However, a known diabetic with a SMBG level of <70 alerts the clinician to
look for further signs and symptoms associated with hypoglycemia.
8.10.7.4.1. The sending facility provides known diabetic patients with a supply of
simple and complex carbohydrates as these food items may not be available on the
aircraft.
8.10.7.4.2. Symptomatic mild hypoglycemia signs and symptoms.
8.10.7.4.2.1. Plasma glucose concentration of <70 mg/dl (if available).
8.10.7.4.2.2. Early signs and symptoms include diaphoresis, tremors, pallor,
tachycardia, palpitations, nervousness. Previous patient history is also valuable.
8.10.7.4.2.3. Later signs and symptoms include light-headedness, headache,
irritability, slurred speech, and weakness.
8.10.7.4.3. Severe hypoglycemia signs and symptoms.
8.10.7.4.3.1. Classified as a severe event if it required the assistance of another
person to initiate resuscitative actions for the diabetic patient.
8.10.7.4.3.2. Severe hypoglycemia can potentially be life-threatening and caused
by an overdose of insulin, a reduction in diet or increased exercise without
sufficient caloric intake.
8.10.7.4.3.3. Signs and symptoms include aggressive or unusual behavior, normal
or rapid respirations, tachycardia, paleness, diaphoresis, headache, dizziness,
fainting, disorientation, confusion, seizure, loss of gag reflex, and loss of
consciousness.
8.10.7.4.3.4. If any signs or symptoms are present, immediately rule out hypoxia.
Concurrently obtain VS, pulse oximetry, ascertain last meal and check a glucose
level if possible.
8.10.7.4.3.5. For all known or suspected hypoglycemic events notify the VFS and
AOC/AECT for guidance and possible diversion to a MTF capable of handling
the situation.
8.10.7.4.4. Treatment/management (reference AE Clinical Protocol – Hypoglycemia
Management).
8.10.7.4.5. Documentation includes subjective and objective data for giving the
medication; VS, known allergies, date and time of administration and notification of a
physician, and the outcome. The following statement is documented on the EHR or
AF Form 3899 “(Insert name of drug) was administered in accordance with AE
Clinical Protocol - Hypoglycemic Management.” Complete a JPSR worksheet or a
DD Form 2852.
8.10.7.5. Diabetic ketoacidosis (DKA). DKA is an acute complication of diabetes
mellitus (usually type I) characterized by hyperglycemia, ketonuria, acidosis and
dehydration. An underlying infection is the most common cause.
8.10.7.5.1. Signs and symptoms include polydipsia, polyuria, fatigue, malaise,
drowsiness anorexia, nausea and vomiting, abdominal pain and muscle cramps.
8.10.7.5.2. Late signs include Kussmaul (dep) respirations and fruity, sweet breath.
8.10.7.5.3. For suspected DKA event, notify the VFS and AOC/AECT for guidance
and possible diversion to a MTF capable of handling the situation. IV fluids, IV
insulin and electrolyte replacement per the VFS orders.
8.11. Decompression Sickness.
8.11.1. Caused by the evolution of free gas bubbles from the tissues and fluids of the body as
a result of marked decreases in barometric pressure. Nitrogen, a metabolically inert gas, is
primarily involved. Nitrogen behaves predictably according to Henry’s Law (reference
paragraph 7.2.3). It evolves in a manner similar to the formation of bubbles in a bottle of
carbonated beverages when the cap is removed.
8.11.2. Stresses of flight affecting patients with decompression sickness.
8.11.2.1. Decreased partial pressure of oxygen: Exacerbates existing hypoxia.
8.11.2.2. Barometric pressure changes: Nitrogen escapes and exacerbates symptoms.
8.11.2.3. Noise, decreased humidity, thermal changes, vibration, and fatigue:
Exacerbates underlying pathology.
8.11.3. Symptoms of decompression sickness. There is no regular sequence, and it is
possible to exhibit various symptoms simultaneously.
8.11.3.1. Skin: Itching, tingling, cold or warm sensations, and occasionally a mottled
rash referred to as the “Creeps.”
8.11.3.2. Joints: Pain in or around the body joints referred to the “Bends.” More
commonly, the larger joints of the elbows, shoulders, knees, and ankles are involved.
8.11.3.3. Respiratory: Deep and sharp sub-sternal pain, dry progressive cough, and a
feeling of suffocation referred to as the “Chokes.”
8.11.3.4. CNS: Most dangerous includes muscular weakness, headache, visual
impairment, speech difficulties, mental confusion, bowel and bladder dysfunction,
paralysis, and coma referred as the “Staggers”.
8.11.3.5. Table 8.9 lists considerations for CNS-injured/Neurologic
Disease/Comatose/Vented Patient.
8.11.4. Preflight/in-flight considerations for patients with decompression sickness.
8.11.4.1. Requires continuous 100% O2 via a tight-fitting mask, unless otherwise
ordered.
8.11.4.2. Requires destination field altitude as the cabin altitude restriction
(recommended) en route.
8.11.4.3. Establish a large bore IV (18 gauge or larger) to maintain hydration.
8.11.4.4. The use of narcotics may mask CNS symptoms.
8.11.4.5. Specifically, for decompression sickness, immobilize joints and maintain
complete bed rest, unless otherwise ordered. WARNING: Trendelenburg position
increases cerebral edema and ischemia and is contraindicated.
8.11.5. Suspect if individual has been scuba diving within the last 24 hours or involved in a
loss of cabin pressurization. Any individual experiencing symptoms during flight needs
prompt treatment.
8.11.5.1. Immobilize the painful area.
8.11.5.2. Request a lower cabin altitude and the AECM notifies C2 who then contacts
the governing PMRC.
8.11.5.3. Possible diversion to a MTF capable of handling the situation, as required.
8.11.5.4. Evaluation by a flight surgeon, even if the symptoms disappear during descent.
8.11.6. Patients en route to the hyperbaric (decompression) chamber may also include the
following diagnoses; carbon monoxide poisoning, gas gangrene, or extensive wound
infections.
8.12. Neurological Management.
8.12.1. Stresses of flight affecting neurological patients.
8.12.1.1. Decreased partial pressure of oxygen: Lower levels of O2 causes brain cell and
tissue ischemia. Brain cell ischemia produces cerebral edema which leads to increased
ICP, then hypoventilation and further hypoxemia. Note: One hypoxic episode in the
presence of traumatic brain injury may lead to a catastrophic secondary brain injury.
8.12.1.2. Barometric pressure changes: Penetrating head injuries, skull fractures and
severe facial fractures may produce air in the cranium, causing increased ICP. The
potential for ear block exists in those patients who have a decreased level of
consciousness, inability to follow directions or a physical disability. Valsalva increases
ICP. Note: A cabin altitude restriction minimizes the stresses of barometric pressure
changes and decreased partial pressure of oxygen.
8.12.1.3. Vibration: May cause motion sickness and vomiting, thus increasing ICP.
8.12.1.4. Thermal Changes: A consideration for patients with hypothalamus
involvement.
8.12.1.5. Decreased humidity: Dries the corneas of patients with decreased corneal/blink
reflex, and possibly increase dehydration and headaches.
8.12.1.6. G-Forces: Takeoff may increase ICP and bleeding for litter patients or
decrease cerebral blood flow to ambulatory patients. Litter patients are secured and
padded on a backrest (if not contraindicated) with the head mid-line. Note: Physician
determines head aft or forward litter positioning for flight.
8.12.2. Traumatic brain injury (TBI).
8.12.2.1. TBI mechanism of injury: Acceleration/deceleration, penetrating/non-
penetrating forces from an explosion/over-pressurized blast wave (the speed of sound),
fall, direct impact, or motor vehicle/aircraft crash. Penetrating TBI is typically identified
and cared for immediately.
8.12.2.2. Types of TBI:
8.12.2.2.1. Closed head injury.
8.12.2.2.2. Skull fractures. WARNING: Do not use a BVM on patients with a skull
fracture to correct ear block.
8.12.2.2.3. Hemorrhage (subdural and epidural hematomas).
8.12.2.3. Management and treatment of TBI. It is essential to complete a baseline
preflight assessment, including pulse oximetry and neurologic checks.
8.12.3. Neurological checks (reference Attachment 11).
8.12.3.1. Immediate TBI signs/symptoms: Alteration in mental status typically resulting
in the temporarily related onset of: Headache, nausea, vomiting, dizziness/balance,
fatigue, insomnia/sleep disturbances, drowsiness, sensitivity to light/noise, blurred vision,
difficulty remembering, and/or difficulty concentrating. WARNING: TBI may be
missed, especially in the presence of other more obvious injuries such as heat or toxic
injury, hypovolemic shock/dehydration, eye and spinal injury, and acute stress reactions.
8.12.3.2. GCS indicators - Moderate TBI = 9-13; Severe TBI = 3-8 (reference
paragraph 8.4.2.2.3).
8.12.3.3. The treatment goals are to prevent the secondary brain injury and progressive
damage from hypoxemia, hypotension, cerebral hypoxia and edema, and to recognize and
to treat the early signs of intracranial hypertension or increasing ICP by maintaining an
adequate airway, monitoring pupils, LOC and the GCS for sudden or subtle changes.
Avoid hypoxia and maintain oxygen saturations >92% with prn oxygen via nasal
cannula. Call C2 and the VFS if O2 saturations are <92%. Reference DoD Policy
Guidance for Management of Mild TBI/Concussion in the deployed Setting and
Management of patients with severe head injury and Table 8.6
Table 8.6. Management and Treatment Considerations/Recommendations for TBI and

Increased ICP.
Management of TBI
Administer Tylenol as ordered for headache
Note: Tramadol, narcotics, non-steroidal anti-inflammatory drug, aspirin, or

other platelet inhibitors are contra-indicated.
Elevate head to increase cerebral venous return
WARNING: Concomitant thoracic or lumbar fractures are transported flat.

Minimize cerebral venous blood volume
WARNING: Prevent endotracheal tube struggle, Valsalva, and overhydrating.
WARNING: Do not use NG tube on patients with skull or facial fractures.
Management of Increased ICP

If “MACE Red Flags” reference Table 8.6 (signs of increased ICP and
paragraph 8.12.4.1.)
Deliver high flow O2 and rule out hypoxia and hypoglycemia

Maintain patent airway, adequate breathing and circulation, a pulse oximeter
reading > 92% or as directed by VFS.
If ordered, implement hyperventilation if patient’s pupil/pupils are dilated and
nonreactive.
WARNING: Excessive hyperventilation/ hyper oxygenation to control

increased ICP without ICP monitoring may have adverse results. Keep assisted
breathing rate < 20/min. If situation occurs in flight, consider lower cabin
altitude if operationally feasible. Notify C2 for guidance and possible diversion
to a definitive care MTF (if required).
If ordered, initiation of hypertonic saline (3%), normal saline not greater than
100ml/hour (if not hypovolemic). May receive mannitol as ordered.
Document I&O
Drug-induced comas require an ERCC team and a ventilator.
8.12.4. Intracranial pressure.
8.12.4.1. Signs and symptoms increased ICP.
8.12.4.1.1. LOC is the most important indicator of brain function.
8.12.4.1.2. Elevated BP with a widening pulse pressure (the difference between
systolic and diastolic).
8.12.4.1.3. Change in pupil size.
8.12.4.1.4. Tachycardia initially, followed by bradycardia as ICP increases.
8.12.4.1.5. Tachypnea (early) and then slowing with lengthening period of apnea.
8.12.4.1.6. Headache: Increasing intensity and may be aggravated with movement.
8.12.4.1.7. Vomiting, with or without nausea, may become projectile.
8.12.4.2. When ICP increases, the body attempts to perfuse the compressed brain tissue
at all cost. Hypotension in head injured patients can be catastrophic because cerebral
blood vessels cannot auto-regulate and therefore cannot constrict to preserve cerebral
blood flow during hypotension. When autoregulation is lost, massive cerebral
vasodilation occurs, and secondarily increases ICP. Monitor patient’s ICP with an arterial
line and ICP monitor (reference Table 8.7).
Table 8.7. ICP and Cerebral Perfusion Pressure (CPP) Parameters.

ICP (mmHg) CPP (mmHg) = MAP-ICP
0-10 Normal 80-100 Average
> 15-18 Treat 60 Possible Brain Ischemia
> 40 Poor Prognosis 40 Irreversible Brain Ischemia
> 60 Probably Fatal 30 Neuronal Cell Death
8.12.5. Cerebral perfusion pressure (CPP).

8.12.5.1. Pressure gradient that drives blood and nutrients into the brain. Normal range:
CPP > 80mmHg. (CPP= MAP-ICP).
8.12.5.2. Dependent upon: Automatic/auto-regulation dilation and constriction of the
cerebral blood vessels to maintain constant blood flow despite fluctuations in the
systemic blood pressure. Normal range: Systolic BP > 90 mmHg, ICP < 20 mmHg.
8.12.6. Military Acute Concussion Evaluation (MACE).
8.12.6.1. Mandatory completion by sending MTF during the first 48 hours for all
individuals involved in an explosion/blast, fall, blow to the head and/or motor
vehicle/aircraft crash who were dazed, confused, “saw stars” or lost consciousness, even
if momentarily (reference Attachment 11).
8.12.6.2. Casualties displaying any of the signs/symptoms in Table 8.8 MACE - Red
Flags are referred for additional medical evaluation as soon as operationally possible. If
new symptoms occur before takeoff, the patient is not stable for flight, and needs to be
cleared by a flight surgeon. Notify Theater PMRC, as soon as possible.
Table 8.8. MACE - Red Flags.

Double vision Seizures
Breathing Difficulties Slurred Speech
Headache that worsens Unsteady on feet
Can’t recognize people or Repeated vomiting
places/Disorientation
Can’t be awakened easily Weakness or numbness in arms/legs
Behaves unusually or seems Progressively declining neurological
confused/irritable exam
8.12.6.2.1. If symptoms manifest in-flight, start high flow O2; the AECM notifies C2
who then contacts the governing PMRC of any change in patient status or
classification as soon as possible.
8.12.6.2.2. MACE scores below 25 may represent clinically neurocognitive
impairment requiring further evaluation for a more serious brain injury.
8.12.7. Spinal cord injuries.
8.12.7.1. The goal is to maintain spine stability and prevent further deterioration of the
patient’s neurological condition during transport. The VFS orders the appropriate
stabilization device.
8.12.7.2. May exhibit signs of shock (reference paragraph 8.8). Note: Rule out TBI
with all spinal cord injuries.
8.12.7.3. May be respiratory-compromised and require ventilator support: “C3, 4, and 5
keep the diaphragm alive;” and T2-8 innervates the intercostal muscles.
8.12.7.4. Disability and dependency is determined by level of injury.
8.12.8. Cerebral vascular accident (CVA).
8.12.8.1. The disruption of cerebral blood supply from ischemia, thrombosis, embolism,
or hemorrhage.
8.12.8.2. CVA assessment:
8.12.8.2.1. Obtain VS, GCS, pulse oximetry, cardiac rhythm, and temperature.
8.12.8.2.2. Signs and symptoms: Altered level of consciousness; sudden, severe
headache; numbness, facial droop, weakness, or unilateral paraplegia; hemiparesis;
slurred speech; dysphagia; aphasia; visual disturbance; and/or altered cognitive
abilities. Note: First rule out TBI with diagnoses of CVA.
8.12.8.2.3. Check blood sugar if on the ground or if ERCC team is on board and treat
if indicated.
8.12.8.3. CVA treatment and management: Reference AHA or equivalent, TNCC if
Table 8.9. Considerations for CNS-injured/Neurologic Disease/Comatose/Vented Patient.

Protect airway If gag reflex diminished
Talk to patient Hearing is last sense to go;
orient to surroundings; explain
procedures prior to performing;
and touch patient while talking
with them. May need to repeat
information several times.
Prevent corneal abrasions Artificial tears and steri-strip lids
closed if corneal reflex absent.
Reposition patient if able Every 2 hours reposition and
massage area to prevent skin
breakdown.
Passive ROM Every 4 hours (if not
contraindicated)
Oral hygiene Every 2 hours
Assist with activities of daily Meals and toileting; MA may be
living required en route
Possible modalities Tube feedings; Foley catheter;
and/or external urinary catheter
Monitor VS (with temperature); pulse
oximetry; GCS; pupils, I&O
8.12.9. Seizures/Status epilepticus. This is a serious neurologic emergency. Status
epilepticus has high morbidity and mortality (permanent brain damage/severe neurologic
deficits). It is characterized by acute, prolonged, repetitive seizure activity or series of
generalized seizures without return to consciousness between attacks. Factors precipitating
status epilepticus in patients with pre-existing seizure disorder include medication
withdrawal, fever, metabolic or environmental stresses, alcohol or drug withdrawal, and
sleep deprivation. The stresses of flight are considered a potential precipitating factor. The
VFS and sending provider determines the need for an IV for patients with a diagnosis of
seizure disorder.
8.12.9.1. Signs and symptoms.
8.12.9.1.1. Staring and subtle body movement.
8.12.9.1.2. Brief loss of awareness.
8.12.9.1.3. Stiffening of muscles especially the back, arms, and legs.
8.12.9.1.4. Rhythmic, jerking muscle movements, usually affecting the neck, face
and arms or sudden brief jerks or twitches of the arms and legs.
8.12.9.1.5. Loss of muscle control, which may cause a sudden collapse or fall to the
ground.
8.12.9.1.6. Loss of consciousness, body stiffening and shaking, and sometimes loss
of bladder control or biting the tongue.
8.12.9.2. Classic signs.
8.12.9.2.1. The seizure lasts more than five minutes.
8.12.9.2.2. Breathing or consciousness does not return after the seizure stops.
8.12.9.2.3. A second seizure follows immediately.
8.12.9.3. Reference AE Clinical Protocol – Status Epilepticus for management and
treatment.
8.12.9.4. Notify the TFVS and AOC/AECT for guidance and possible diversion to a
MTF capable of handling the medical emergency.
8.12.9.5. Documentation in the EHR or AF Form 3899 of the use of the AECP includes
the subjective and objective assessments leading up to, during, and post seizure activity
and include:
8.12.9.6. A description of the seizure activity (body movement and presentation of
tonic/clonic states).
8.12.9.6.1. Presence of a preceding aura.
8.12.9.6.2. Order of symptoms.
8.12.9.6.3. Position of the eyes (open or closed), pupil size changes (did they change
together or individually).
8.12.9.6.4. Incontinence of urine or feces.
8.12.9.6.5. If there was a loss of consciousness and how long it lasted.
8.12.9.6.6. Observation of chewing of the mouth, biting the tongue and/or rolling of
the eyes.
8.12.9.6.7. Skin appearance, clammy/flushed/ashen.
8.12.9.6.8. Compliance with medication regime (if known).
8.12.9.6.9. Complete set of vitals, date, and time of medication administration, and
VFS notification.
8.12.9.6.10. Documentation of any medication administered in accordance with the
AECP.
Table 8.10. Seizure Precaution and Treatment.

Prior to Seizures
Maintain airway Maintain adequate breathing and circulation
(pulse oximetry >92% or as directed by
VFS).
Maintain Ordered medication regimen and
patent IV (if clinically indicated).
Position near Oxygen and suction.
Position away from Windows near propellers/rhythmic
flashes of light.
During Seizures
Protect from injury Assist to floor; recline the seat; do not
restrain; position to side to prevent
aspiration.
Prepare to Suction; apply high flow O2; and/or
assist respirations. DO NOT attempt
placing a bite block.
Observations to record - Assess for aura; rigidity superseded
by jerks/ convulsions? When/where
did this occur and in what order?
- Did the body change position during
the seizure?
- Did you observe any chewing of the
mouth, biting tongue and/or rolling of
the eyes?
- If the eyes where open, what did the
pupils look like? Did they change in
size? Together or individually?
- What was the respiratory pattern?
- What was the skin appearance?
Flushed/ashen/clammy?
- If unconscious, how much time
elapsed before the patient regained
consciousness?
- Was the patient incontinent of urine
or feces?
- Did the patient sleep afterwards? If so,
how long?
Treatment After Seizure (Postictal)
Maintain airway/breathing Rule out hypoxia.
100 DAFI48-107V1 15 DECEMBER 2020
Litter As needed.
Obtain VS, neurological assessment Pulse oximetry and detailed neurological
assessment.
Postictal Improving - Maintain seizure precautions and O2.
- Decrease stimuli as much as possible.
- Minimize the situation if patient has
chronic seizure history.
- Provide support, reassurance, and comfort
.
8.13. Musculo-Skeletal System/Wound Disorders/Injuries.
8.13.1. Stresses of flight affecting patients with musculo-skeletal and wound
disorders/injuries.
8.13.1.1. Decreased partial pressure of oxygen: Exacerbates the effects of hemorrhage,
shock, and low H&H.
8.13.1.2. Barometric pressure changes: May contribute to compartment syndrome if
patient is in a circumferential cast or resultant condition causes extremity hypo-perfusion.
8.13.1.3. Vibration: Severe jarring may affect alignment and/or positioning of
unstabilized fractures. Vibration alone can increase pain at fracture sites.
8.13.1.4. Humidity: May lead to dehydration predisposing individuals to VTEs and may
also cause skin dryness over time, leading to itching under cast.
8.13.1.5. Thermal: Changes of temperature may compromise circulation and increase
pain; patient can sweat under cast/dressings on the flight line and then become cold at
altitude.
8.13.2. Preflight/in-flight considerations.
8.13.2.1. Neurovascular assessment: Compare to unaffected extremity. Important to
obtain a baseline assessment prior to flight to recognize changes during flight. Sensation:
Compare to peripheral nerve block side to unaffected side. Assess level of epidural
effectiveness, utilizing the dermatome map in Figure 8.1
8.13.2.2. Peripheral pulse qualities (proximal/distal to injury). Presence does not rule out
injury; re-assess frequently and compare to unaffected extremity.
8.13.2.3. Capillary refill less than two seconds is normal. Can be hard to assess in
dark/shadows, affected by extremity temperature, staining of extremity with blood/prep
solutions.
8.13.2.4. Presence of edema. Remove constricting items above and below the injury
(rings and watches, tight clothing, tight dressings/splints; casts are bivalved unless
contraindicated).
8.13.2.5. Color and temperature. Affected by ambient temperature, therapeutic cooling,
Peripheral Nerve Block (PNB)/epidural catheter.
8.13.2.6. Motor function. Affected by PNB/epidural catheter.
8.13.2.7. Reassess after position change and immobilization.
DAFI48-107V1 15 DECEMBER 2020 101
8.13.2.8. Instruct the patient to report any pain and motor sensory changes (tingling,
numbness, weakness, increasing pain).
8.13.2.9. External fixators: pin care is completed during preflight. Fixators may be
handled/manipulated by medical care personnel (nursing care/transportation/wound care)
and used to transmit traction to affected limb in select situations (skeletal traction).
Fixators may also be suspended from fixed devices in select situations (preparation for
surgery or edema control).
8.13.3. Considerations for orthopedic and soft tissue injuries.
8.13.3.1. Ensure skin integrity remains intact.
8.13.3.2. Maintain injured extremity/fracture immobility to control bleeding, maintain
circulation, and to prevent fat embolism.
8.13.3.3. Maintain traction if applicable. WARNING: Do not use free hanging weights
in-flight. WARNING: Stagnant positions for extended periods of time, and/or injury and
infection may lead to a VTE or a blood clot deep in the tissues of the calves or groin.
Thrombosis prophylaxis is part of preflight assessment. Ensure stability when using the
following equipment
8.13.3.3.1. Stryker ® frame.
8.13.3.3.2. HALO/external fixation.
8.13.3.3.3. C-Collar, backboard, vacuum spine board or other non-shifting medium.
8.13.3.3.4. Hare, Sager, Kendrick traction devices and Thomas splints.
8.13.4. Compartment syndrome: The compromise of muscle viability due to swelling of or
bleeding into tissues encased within the fascial sheath of an extremity. Resultant pressure
change in the extremity blocks venous outflow and subsequent “backup” of blood flow,
ultimately preventing arterial inflow. Associated with open/closed fractures, external
fixation/skeletal devices, compression/crushing injuries or constrictive bandages/casts,
vascular injuries, burns. Can occur in upper and lower extremity injuries. WARNING: This
is a limb-threatening emergency.
8.13.4.1. Assess for signs and symptoms: Classic signs of edema, pulselessness, pallor,
paresthesia, or sensory deficit with late signs of paralysis and cyanosis. Severe
unremitting pain, pain on passive stretch of muscle or pain that is out of proportion to
what is expected by the provider and compartment firmness are earliest signs.
Compartment pressure measurement with invasive needle device is not required for
diagnosis but can be used by physicians in obtunded/sedated patients.
8.13.4.2. Treatment and Management.
8.13.4.2.1. Remove constrictive dressings. Consider bivalving prior to leaving the
MTF if cast is less than 48 hours old unless otherwise ordered by sending physician
or VFS (reference paragraph 8.5.2).
8.13.4.2.2. Maintain extremity at heart level. Neither elevation nor dependency of the
extremity has been shown to benefit. Do not elevate extremity above the level of the
heart.
102 DAFI48-107V1 15 DECEMBER 2020
8.13.4.2.3. Administer pain medication after assessment. WARNING: Frequently

assess adequacy of pain control measures. Pain medicine is often inadequate to
control the symptoms of CS, and even when successful, could potentially hide the
emergent nature of the problem. This is a surgical emergency. The measures listed
here are of potential benefit in an impending compartment syndrome, but once
established these patients need fasciotomy. The AECM notifies C2 who then contacts
the governing PMRC to consider diversion to a location where surgical care is
available.
8.13.5. Amputation: Control bleeding and pain. Assess dressings. Amputation stumps are
prone to swelling, causing initially adequate dressings to become compressive. If the limb
has been fitted with a prosthesis, the socket or sleeve may become too tight or loose and
require removal.
8.13.6. Pelvic fractures: Complete bed rest. May have external fixation devices. Assess VS
and assess distal pulses regularly. Extensive blood loss and internal vascular injuries are
associated with pelvic fractures. PE/VTE prophylaxis is essential (reference paragraph 8.6).
8.13.7. Application of splints or wraps:
8.13.7.1. Proper splint placement: Splint the joint above and the joint below the injury
(Do not splint the shoulder when splinting an elbow and do not splint the hip when
splinting the knee).
8.13.7.2. Proper alignment: In the position of function/comfort as long as distal
perfusion and neurological exam unchanged.
8.13.7.3. Security of splint/ace. Re-wrap if too tight or too loose.
8.13.7.4. Air splints: WARNING: Air expands at altitude. Requires close observation
and adjustments during ascent, at altitude and descent, and are not be used in-flight if
alternate splinting devices are available.
8.13.7.5. Positioning and alignment.
8.13.7.5.1. Reposition every two hours with pillows.
8.13.7.5.2. Pad and elevate extremities. WARNING: Do not tie extremities to any
portion of the aircraft to maintain elevation.
8.13.7.6. ROM exercises.
8.13.7.7. Avoid resting extremities on the bulkhead or the interior of the aircraft due to
effects of vibration.
8.13.7.8. Spica casts require two litter spaces (these are now rare, usually confined to
pediatric patients, special attention to toileting needs is required).
8.13.7.9. Mobility impaired ambulatory patients are not seated near emergency exits.
8.14. Wound Management.
8.14.1. Provider’s orders for all wound management include frequency of dressing changes
and type of wound care, including surgical debridement.
8.14.2. All combat wounds are considered contaminated and may not be closed initially.
DAFI48-107V1 15 DECEMBER 2020 103
8.14.3. Note type and amount of drainage on dressings. Do not change dressings, reinforce
only, on the aircraft.
8.14.4. Any wound associated with a fracture is managed as if it was an open fracture and
treatment is started within eight hours. This includes debridement, when appropriate, and IV
antibiotics prior to and during flight.
8.14.5. Monitor for increased temperature. Note presence of drains (note amount, color, and
location).
8.14.6. Control bleeding with direct pressure, elevation, and pressure points. If that is not
effective, a tourniquet or Quick Clot may be used if available. Note: The Aircraft First Aid
Kit contains a tourniquet and Quick Clot. Monitor BP closely in actively bleeding patients.
The AECM notifies C2 who then contacts the governing PMRC of any change in patient
status or classification as soon as possible.
8.14.7. Pain medication, as ordered. Frequently assess adequacy of pain control measures.
Avoid over-sedation and nausea, especially in supine patients.
8.14.8. Wound drainage tubes (Jackson-Pratt [JP], T-tube, Hemovac etc.).
8.14.8.1. Assess insertion site and assure suction is maintained at altitude, if indicated.
8.14.8.2. Document I&O.
8.14.8.3. Use standard precautions for disposal of blood and body fluids.
8.14.9. Negative-pressure wound therapy (NPWT).
8.14.9.1. NPWT systems are generally indicated for the management of wounds, burns,
ulcers, flaps, and grafts. NPWT applies negative pressure to the wound to remove fluids,
including wound exudates, irrigation fluids, and infectious materials. Benefits of NPWT
include augmented wound granulation, wound contraction, improved control of wound
exudates, decreased wound edema, reduced skin maceration, and improved pain
management.
8.14.9.2. NPWT is contraindicated in the presence of exposed anastomotic sites, exposed
vasculature, exposed nerves, exposed organs, necrotic tissue with eschar present,
untreated osteomyelitis, non-enteric and unexplored fistulas, and malignancy in the
wound. Also, carefully consider the use of this therapy in patients with certain risk
factors, including those with a high risk for bleeding and hemorrhage, and those receiving
anticoagulants or platelet aggregation inhibitors.
8.14.9.3. Do not continue therapy in-flight if problems occur on the ground preflight.
8.14.9.4. Assess patient comfort and system functioning every two hours in-flight.
8.14.9.4.1. Be vigilant for potentially rare life-threatening bleeding complications.
8.14.9.4.2. NPWT is not be interrupted for greater than two hours within a 24-hour
period due to the potential for infection.
8.14.9.4.3. Assess proper function by examining for alarms on the pump unit and
inspecting the dressing. The dressing for a properly functioning system has a “raisin-
skin” appearance.
104 DAFI48-107V1 15 DECEMBER 2020
8.14.9.4.4. WARNING : The NPWT may cease effective pressure if the occlusive
dressing is not sealed. Occlusive reinforcement may need to be applied.
8.14.9.4.5. For non-correctable NPWT system failures in-flight, the overlying
occlusive film is opened by making two to three slits into the film to allow for wound
drainage. DO NOT remove the occlusive film or the sponge inside the wound for risk
of bleeding or wound contamination. A dry dressing is then applied over the site and
reinforced as needed. Report wound vacuum system failure and actions taken to
receiving facility during hand off for follow-on care. Complete a JPSR worksheet or
DD Form 2852 and notify C2 at end of mission. WARNING: Do not interchange
different types of NPWT devices and dressings. Other suction units may not provide
adequate and consistent suction thereby increasing risk of infection.
8.14.9.4.6. Extra NPWT canisters are available in the event the current ones become
full or cracked. Note: This guidance is for use in-flight if a full system failure occur.
If NPWT system failure occurs while on the ground, at originating station, or during
en route stops contact the appropriate TPMRC.
8.14.9.5. Document amount of drainage from the NPWT canisters.
8.15. Medical Devices.
8.15.1. Special considerations are made to ensure extremities and devices are not impeding
egress of the aisles and exits.
8.15.2. Casts. Casts are bivalved if tissue edema and vascular compromise is possible, or if
cast restricts emergency egress. Cast cutters are not available in-flight. If casts are not to be
bivalved, specific orders “Do not Bivalve for flight” are written on proper documentation.
8.15.2.1. If the cast is over a surgical wound site, “window” the cast to allow for tissue
expansion. Always replace the “window” in the cast after assessment to prevent focal
edema through the window.
8.15.2.2. Assess cast for: Proper drying, cracks, rough edges, drainage, and bleeding
(outline, date and time site), foul odor, and pressure points.
8.15.2.3. Perform circulation and neurovascular checks prior to flight. If abnormal,
contact the MTF to bivalve the cast or loosen the bivalved cast. Cast padding can be cut
on both sides with scissors to further reduce compression if necessary, without
compromising immobilization.
8.15.2.4. Patients with crutches or full leg casts, or whose condition prevents them from
using seats, are classified, and transported as litter patients. The AECM is final authority
on whether patients are enplaned via litter. Note: Crutches and canes accompany patients
who require such items.
8.15.3. The Stryker® Wedge Turning Frame 965 Military Option (reference AFMAN 10-
2909 and the AE Medical Equipment Compendium).
8.15.4. Vacuum spine board (VSB).
8.15.4.1. Purpose is to provide full body immobilization for suspected spine, pelvic, hip
fractures, and patients with multiple fractures.
DAFI48-107V1 15 DECEMBER 2020 105
8.15.4.1.1. VFS provides appropriate documentation requesting use of VSB and have
ERCC team assigned to patient.
8.15.4.1.2. Originating facilities are responsible for assisting ERCC team with
putting the patient on the VSB.
8.15.4.1.3. Always use a cervical collar (C-Collar), in conjunction with the VSB, if
C-Spine injury is suspected.
8.15.4.1.4. Patients requiring spinal traction, or lying prone position, are transported
on a Stryker not with a VSB.
8.15.4.1.5. VFS considers if patient needs VSB or can be transported in C-Collar on
NATO litter with AE mattress.
8.15.4.1.6. Preventative measures are taken to protect the occiput, back, coccyx and
heels.
8.15.4.1.7. If total transport time is anticipated to be greater than 10 hours, open the
VSB valves every 2 hours, release straps, safely adjust the position (ensuring
appropriate alignment is maintained), to ensure adequate time for relief of pressure
points. Note: If contraindicated, a credentialed provider writes an order not to deflate
the VSB and adjust the position of the patient. Documentation includes why deflation
of the VSB, and re-positioning was not completed.
8.15.4.1.8. Conduct thorough skin assessment prior to placing on VSB and ensure
documented on the EHR or AF Form 3899.
8.15.4.2. In-flight nursing considerations for the VSB.
8.15.4.2.1. The black litter mattress is placed on the NATO litter and the VSB on top
of mattress. Ensure the hand pump accompanies the patient.
8.15.4.2.2. Patient are not be transported without use of a NATO litter/Over-Sized
Litter and AE mattress.
8.15.4.2.3. Apply straps in accordance with AE Medical Equipment Compendium
and the ERCC Team.
8.15.4.2.4. Do not retighten chest or abdominal straps after suction applied, as over
tightening may restrict chest wall movement and affect breathing.
8.15.4.2.5. Patients are repositioned every two hours unless otherwise ordered and
documented. Turn schedule is documented on the EHR or AF Form 3899. AECMs
are responsible for assisting with turning/repositioning patient with ERCC team
members. The AECM coordinates turn schedule and any special requirements with
ERCC team physician.
8.15.4.2.6. Monitor occiput, back, coccyx and heels for signs of skin breakdown.
8.15.4.2.7. Monitor patient temperature regularly as part of VS assessment. Note:
VSB may retain heat and cause elevated temperature.
8.15.4.2.8. Optimally maintain respiratory and hemodynamic parameters.
8.15.4.2.9. Ensure gastric decompression (as required).
106 DAFI48-107V1 15 DECEMBER 2020
8.15.4.2.9.1. Ensure suction is easily accessible in all phases of transport.

8.15.4.2.9.2. If patient vomits, if able, tilt the litter by lowering the
stanchion/straps on one side.
8.15.4.2.10. Assess for pain, tenderness, sensation (dermatome level) with VS and
document on the EHR or AF Form 3899.
8.15.4.3. VSB deplaning considerations.
8.15.4.3.1. Brief deplaning procedures: Ensure VSB straps and all litter straps are
secure.
8.15.4.3.2. Ensure IV tubing, urinary catheter tubing and collection bag are secure.
8.15.4.3.3. Patient are in supine position for landing and ground transport.
8.15.4.3.4. Deplane patient, using (minimum) four person carry ensuring all
personnel are briefed in proper lifting and carrying techniques.
8.15.4.3.5. Ensure documentation of post-flight skin condition documented on the
EHR or AF Form 3899.
8.15.4.4. VSB cleaning.
8.15.4.4.1. Ensure VSB valve is closed. Use normal detergents/cleaners to disinfect.
May hose off/wipe down with cold water if soiled.
8.15.4.4.2. All straps are removable for cleaning in washing machine. Follow
manufacturer instructions.
8.16. Eyes, Ears, Nose, and Maxillofacial Management.
8.16.1. Eyes.
8.16.1.1.1. Decreased Partial Pressure of Oxygen: May cause increased intraocular
pressure and vasodilatation due to hypoxia and may aggravate retinal hemorrhage,
detached retina, and glaucoma.
8.16.1.1.2. Barometric pressure changes: Causes increased pressure with pain and
reduced blood flow to the eye. Post-op eye surgery patients may have trapped air in
the globe; certain gases used in surgery may persist three to nine weeks. A closed
penetrating eye injury may also have trapped air in the globe; air normally is
reabsorbed in three days. Expanding air at altitude may lead to increased pressure,
pain and/or extrusion of eye contents.
8.16.1.1.3. Decreased humidity: Excessive drying of the eyes leads to corneal
irritation and abrasions of the sclera, especially in comatose patients or patients
whose eyes do not completely close.
8.16.1.1.4. Vibration/thermal/turbulence: Leads to motion sickness, vomiting, and
increased intraocular pressure and pain.
8.16.1.2. Preflight/in-flight considerations.
8.16.1.2.1. Chemical Injuries.
DAFI48-107V1 15 DECEMBER 2020 107
8.16.1.2.1.1. Immediately begin copious irrigation with NS or balanced salt

solution.
8.16.1.2.1.2. Assess extent of visual impairment/in-flight risks.
8.16.1.2.1.3. Shield and transport.
8.16.1.2.2. Traumatic Injuries.
8.16.1.2.2.1. Avoid any maneuver that places pressure on the globe. Do not place
any dressing under the shield or that touches the eye. Do not place a head wrap
over an unshielded eye.
8.16.1.2.2.2. Shield with a rigid eye shield or an alternative such as a cup, the
casualty’s eye armor or other device that does not place pressure on the globe.
8.16.1.2.2.3. Do not attempt to open the eye. Do not remove foreign bodies. Do
not use topical anesthetics. Shield and transport.
8.16.1.2.3. Suspect air in the globe with recent surgery and penetrating eye injuries
(may also have associated facial trauma/burns and head and C-Spine injuries).
8.16.1.2.4. Post-op eye surgery patients are cleared by an ophthalmologist prior to
flight. Note: O2 requirements needed during flight are ordered by the
ophthalmologist, or the VFS, if the ophthalmologist is not available.
8.16.1.2.5. Successful outcomes for penetrating eye injuries with documented air in
the globe are highly dependent on rapid transportation to specialized care. Maintain
the cabin altitude restriction which may be ordered by the VFS. Note: Flying at
lower altitudes may decrease speed and increase fuel consumption; however, rapid
transportation to definitive care takes precedence.
8.16.1.2.6. Hyphema or blood in the anterior chamber may re-bleed two to seven
days post-injury. Re-bleeding may cause pain and substantial visual disability or
blindness.
8.16.1.2.7. Medication: Is ordered on the appropriate patient treatment form and
provided by the originating MTF. Prescribed eye drops may affect vision.
8.16.1.2.8. Patients with suspected bacterial or viral eye infections do not have eye
patches.
8.16.1.2.9. Patients with a severe detached retina or penetrating injury are on
complete bed rest on a litter with the head immobilized, bilateral eye patches, and O2
in-flight. Note: Signs and symptoms of detached retina: Light flashes, floating
black spots, curtain-like narrowing of peripheral vision.
8.16.1.2.10. If vision worsens or pain and drowsiness develop en route:
8.16.1.2.10.1. Assess oxygenation. Administer high flow O2 and call C2.
8.16.1.2.10.2. The AECM notifies C2 who then contacts the governing PMRC
for guidance and possible diversion to a MTF capable of handling the situation, as
required.
108 DAFI48-107V1 15 DECEMBER 2020
8.16.1.2.11. May have diminished corneal/blink reflex: Use artificial tears as often
as needed.
8.16.1.2.12. Consider a preflight antiemetic for motion sickness.
8.16.1.2.13. May ambulate during enplaning/deplaning with assistance, if not
contraindicated.
8.16.1.2.14. Position in seats away from emergency exits, near an able-bodied
individual, inboard, with the good eye toward the aisle. Positioning is the same for the
blind patient.
8.16.1.2.15. Consider administering preflight nasal decongestant to prevent ear
block. Prevention of ear block starts at originating MTF. Evaluate risk for ear block.
Brief patients on signs and symptoms, as well as techniques to prevent potential ear
block (if not contraindicated), and to notify AECM immediately if difficulty in
clearing ears occurs. Note: Blast victims are evaluated and treated for possible
infection and trapped air following ruptured tympanic membranes; tape dressing to
absorb blood and fluid from the external ear canal, and monitor to ensure it does not
block or enter the external canal. WARNING: Valsalva is not performed by patients
with acute eye injuries, post-op eye surgery, glaucoma, detached retina, hyphema.
These patients are evaluated by a flight surgeon prior to flight and have decongestants
available.
8.16.1.2.16. Information for patients with vision impairment.
8.16.1.2.16.1. Noise may be excessive and unfamiliar.
8.16.1.2.16.2. Instruct on clearing of ears on descent.
8.16.1.2.16.3. Provide assistance and preplan for emergencies by assigning an
able-bodied individual or AECM.
8.16.1.2.16.4. Provide information on scheduled meal plan, lavatory location,
destination and, estimated time of arrival information, as well as how to notify an
AECM if needed.
8.16.1.2.16.5. Assist with meals, restroom, ambulating as necessary.
8.16.1.2.16.6. Seeing eye dogs. Patient may have a service animal (reference
paragraph 10.16).
8.16.2. Ears.
8.16.2.1.1. Barometric pressure changes: Gas expansion or contraction affects the
middle ear when pressure in the air-filled cavities does not equalize with the cabin
pressure. Equalization depends on the patency of the eustachian tube. During ascent,
pressure is normally passively vented. During descent, the eustachian tube needs
active “opening” as the pressure becomes negative.
8.16.2.1.2. Noise: Exposure for even a short period of time can lead to tinnitus, mild
to severe pain, fatigue, and temporary to permanent hearing loss. Position away from
high noise areas of aircraft and provide ear protection.
DAFI48-107V1 15 DECEMBER 2020 109

8.16.2.2.1. Ear block. Potential patients at risk are: Upper respiratory infections
(URI), sinus infections, allergies, otitis media, on high-flow O2, facial injury, nasal
packing, infants, post-ears-nose-throat (ENT) surgery, difficulty swallowing,
language barriers, unconscious/comatose patients.
8.16.2.2.2. Prevention techniques. The following may help prevent ear blocks on
descent: Swallowing, yawning, moving jaw from side to side, chewing gum,
Toynbee maneuver (swallowing water with the nostrils closed), valsalva (the action
of attempting to exhale with the nostrils and mouth or the glottis, closed). This
increases pressure in the middle ear and is used as a means of equalizing pressure in
the ears. If the patient is able to turn their head away from the blocked ear and stretch
the opposite ear to the shoulder, this stretches the eustachian tube of the blocked ear,
which may facilitate the valsalva. WARNING: With certain diagnoses (e.g.,
glaucoma, recent eye surgery or injury, nasal/facial fractures, post-operative nasal
surgery, history of aneurysm, acute head injuries, severe hypertension, cardiac disease
and arrhythmias, and neurological disease with ICP) valsalva is contra-indicated.
Assess for signs/symptoms. Fullness, pain (mild to severe), pressure in ear(s),
decreased hearing (mild to acute), vertigo, and tinnitus.
8.16.2.2.3. Treatment/management.
8.16.2.2.3.1. Premedicate with oral or nasal decongestants unless contraindicated
per VFS.
8.16.2.2.3.2. AECM may delay transport if patient is unable to “clear” ears or if a
cabin altitude restriction is required but operationally unrealistic. The AECM
notifies C2 who then contacts the governing PMRC for guidance.
8.16.2.2.3.3. Ensure parents of infants/children have full bottle or cup with straw
to aid in clearing of ears.
8.16.2.2.3.4. If unable to clear ears during descent, have the PIC reascend and
slow the rate of cabin descent, if operationally possible.
8.16.2.2.3.5. Medications per AE Clinical Protocol – Over-the-Counter
Medication Administration.
8.16.2.2.4. To use BVM to clear the ears: The patient is alert and oriented. Two
AECMs may be required. Patients are placed in the sitting position with the affected
ear pointed towards the ceiling. One AECM stands behind the patient and hold the
BVM mask up against the face. The other AECM stands in front of the patient and
does a verbal count (one, two, three) and squeeze the bag at the same time as the
patient swallows.
8.16.2.2.4.1. Document and reassess patient after landing. Requires ongoing
evaluation if there are other en route stops.
8.16.2.2.4.2. Assess if the patient is able to clear ears and is pain free to continue
flight and if an evaluation by a flight surgeon is required.
8.16.2.2.4.3. Direct patient and MTF representative to seek evaluation at
110 DAFI48-107V1 15 DECEMBER 2020
destination MTF.
8.16.3. Nasal.
8.16.3.1.1. Barometric Pressure Changes: Any obstruction of the nasal passage can
result in an ear/sinus block (e.g., facial fractures, nasal packing, nasopharyngeal tube
and/or NG).
8.16.3.1.2. Decreased humidity: Can cause drying of mucous membranes,
thickening of secretions and increased risk of epistaxis (nosebleed).
8.16.3.1.3. Vibration: May cause pain and increased bleeding in facial fracture
patients.
8.16.3.2.1. Decongestant prior to flight (if not contraindicated) per VFS orders.
8.16.3.2.2. May require a cabin altitude restriction.
8.16.3.2.3. Anterior bleeding (most common).
8.16.3.2.3.1. Lean forward in a sitting position and encourage mouth breathing.
8.16.3.2.3.2. Pinch nostrils for four to ten minutes, and place cold packs to the
posterior neck and bridge of nose, if available.
8.16.3.2.4. Posterior bleeding.
8.16.3.2.4.1. Are not be transported if known to be actively bleeding.
8.16.3.2.4.2. Sit up to allow drainage.
8.16.3.2.4.3. Monitor VS; may be hypertensive.
8.16.3.2.4.4. Initiate IV for blood loss greater than 240ml and the AECM notifies
C2 who then contacts the governing PMRC of any change in patient status or
classification as soon as possible.
8.16.3.2.4.5. If nasal packing is present, leave in place. If a foley is being used for
nasal packing, have the physician fill it with NS prior to flight.
8.16.3.2.4.6. Encourage fluids en route.
8.16.4. Sinus block.
8.16.4.1. Sinuses normally equalize and vent during ascent. On descent, individuals who
have colds, allergies, and chronic or acute sinus conditions, are more at risk for sinus
blocks.
8.16.4.2. Prior to flight, brief patients on signs and symptoms, and how to notify
AECMs. Premedicate with oral analgesic or mild vasoconstrictors per VFS orders.
8.16.4.3. Assess for signs/symptoms: Include pain (mild to severe), burning sensation,
and tenderness over the affected sinus, bloody/mucopurulent discharge, teary eyes, and a
sucking/crackling noise in the sinus area.
DAFI48-107V1 15 DECEMBER 2020 111
8.16.4.4. Position in a seat or with head of litter elevated.

8.16.4.5. Provide humidification, force fluids.
8.16.4.6. Sinus block occurs, treatment includes:
8.16.4.6.1. Coordinate with the PIC to ascend from the current altitude or request a
slower rate of descent.
8.16.4.6.2. Medications per AE Clinical Protocol – Over the Counter Medication
Administration.
8.16.4.6.3. Observe for relief of pain, pressure, and bleeding/drainage.
8.16.4.6.4. Evaluation by a flight surgeon at en route stop or RON to assess whether
the patient may continue with the mission. If the patient continues the mission,
coordinate slower descents and provide patient with vasoconstrictor for the
subsequent descents; may require a cabin altitude restriction. Observe for
bleeding/drainage.
8.16.5. Maxillofacial.
8.16.5.1.1. Barometric pressure changes: Gas may become trapped or partially
trapped in sinuses and teeth, increasing pain.
8.16.5.1.2. Decreased humidity: Causes mucous membranes to dry out leading to
pain and/or discomfort.
8.16.5.1.3. Vibration: May increase pain and exacerbate underlying condition.
8.16.5.2.1. Pharyngeal injuries less than 72 hours old require a tracheostomy prior to
flight.
8.16.5.2.2. Jaw immobilization: Assess for type of immobilizer and release
mechanisms. Have suction set up and available next to patient.
8.16.5.2.2.1. Wired jaw: Ensure wire cutters or scissors are attached to the
patient.
8.16.5.2.2.2. Quick release mechanism: Ensure the patient and AECMs know
how to operate.
8.16.5.2.2.3. Anti-emetics to prevent vomiting per VFS orders.
8.16.5.2.2.4. Only in an emergency (e.g., possible loss of airway) release the jaws
when vomiting is likely. Restabilize with cravat or wrap.
8.16.5.2.2.5. Liquid diet.
8.16.5.2.2.6. Patient’s classified for a litter require a backrest prior to flight.
Ambulatory patients require a seat.
8.16.5.3. Teeth.
112 DAFI48-107V1 15 DECEMBER 2020
8.16.5.3.1. Tooth pain may be associated with trapped gas in a decayed tooth or
pressure on the tooth below the blocked sinus. May require a cabin altitude restriction
until tooth is evaluated and treated. Have a flight surgeon evaluate the patient prior to
flight.
8.16.5.3.2. If pain occurs at altitude, descend until pain is diminished, if operationally
possible and document and communicate with receiving MTF for further evaluation.
8.17. Gastrointestinal (GI)/Genitourinary/Tube Management.
8.17.1. Stresses of flight.
8.17.1.1. Barometric pressure changes: Gas expansion may cause increase in nausea and
abdominal discomfort, vomiting, decreased lung expansion and volume, and may require
NG tube decompression preflight or in-flight.
8.17.1.2. Vibration: May exacerbate patient’s underlying condition or diagnosis and
make more susceptible to motion sickness.
8.17.1.3. Thermal: Underlying condition or diagnosis may make the patient more
sensitive to thermal changes.
8.17.1.4. Fatigue: May exacerbate the patient’s condition.
8.17.1.5. Decreased humidity: May lead to dehydration.
8.17.1.6. G-Forces: Turbulence and acceleration changes can be exaggerated in the rear
of the aircraft. This can lead to an increase in motion sickness in susceptible patients.
Consider placing patients who are susceptible to motion sickness, forward or over the
wing to reduce the exaggeration of changes in the aircraft.
8.17.2. Acute abdomen.
8.17.2.1.1. Current and past disease processes may present or exacerbate in-flight.
History includes, but is not limited to, previous abdominal surgeries, adhesions,
intestinal obstruction, neoplasms, ulcerative colitis, kidney disease, cardio-pulmonary
disease, pregnancy, and stroke.
8.17.2.1.2. Assess for signs and symptoms: Fever, chills, abdominal pain, nausea,
vomiting (bilious, feculent, blood, and/or coffee-ground appearance), dysuria, and
hematuria. There may also be fluctuations in BP.
8.17.2.1.3. Assess VS, bowel sounds and percuss the abdomen preflight.
8.17.2.2. Acute abdomen: Treatment/management.
8.17.2.2.1. NPO. Monitor I&O.
8.17.2.2.2. Insert a NG tube if there is gastric distention, nausea and vomiting are
severe, and/or if the airway may be compromised. Note: If symptoms occur preflight
or inflight, the patient is not stable. The AECM notifies C2 who then contacts the
governing PMRC for guidance and possible diversion to a MTF capable of handling
the situation.
8.17.3. GI Bleeding.
DAFI48-107V1 15 DECEMBER 2020 113

8.17.3.1.1. Seen in trauma to the GI tract; inflammatory/ulcerative disease, response
to stress, varices, alcohol, aspirin compounds anticoagulants for coagulation
abnormalities, VTE, heart valve replacement; neoplasms, and hemorrhoids or
fissures.
8.17.3.1.2. Assess for signs and symptoms: Bright red or “coffee grounds” emesis,
tarry stool or coating of stool.
8.17.3.1.3. NG tube will not have active bleeding or coffee ground material preflight.
(T-0).
8.17.3.1.4. Usually is not airlifted less than three days post-GI bleed. Orthostatic
postural changes (measure BP and pulse: Supine-to-sitting-to-standing; a twenty-
point pulse increase or a systolic 10% decrease is positive for orthostatic postural
changes and may need fluids or blood administered) are not present.
8.17.3.1.5. Should have a preflight H&H (Hgb > 8 g/dL and HCT > 25 %) and O2 at
2-4 LPM in-flight per VFS orders. Note: For patients with a HCT below 24% strong
consideration is given for patient to receive blood product replacement, repeat H&H
and cleared by VFS prior to flight.
8.17.3.1.6. Obtain preflight VS, including pulse oximetry.
8.17.3.2.1. NPO. Monitor I&O.
8.17.3.2.2. IV access for medications and fluid replacement.
8.17.3.2.3. Onset of upper GI bleeding in-flight. Initiate treatment and the AECM
notifies C2 who then contacts the governing PMRC for guidance and possible
diversion to a MTF capable of handling the situation.
8.17.3.2.3.1. Administer high flow O2 to maintain pulse oximetry at or above
92% or as directed by VFS.
8.17.3.2.3.2. Start LR or NS with large bore IV access to maintain BP, heart rate
and UOP. If blood infusion tubing is used, prime with NS.
8.17.3.2.3.3. Litter for comfort.
8.17.3.2.3.4. Assess and address the underlying cause, if known.
8.17.3.2.3.5. Consider NG tube insertion.
8.17.4. Chronic GI conditions.
8.17.4.1. Bowel inflammation, peptic ulcer, and enteritis (Crohn’s Disease and
Ulcerative Colitis).
8.17.4.2.1. Consider proximity to bathroom, medications, hydration, and diet
restrictions.
8.17.4.2.2. Special diet: AE crew makes certain the diets are onboard.
114 DAFI48-107V1 15 DECEMBER 2020
8.17.4.2.3. Ostomy patients may have more bowel movements due to gas expansion.
8.17.4.2.3.1. Ensure patient has extra bags, wafers, and stoma adhesive.
8.17.4.2.3.2. Empty contents preflight. Check immediately after ascent. Vent bag
if possible. Note: If non-venting colostomy apparatus, vent collection bag to
avoid excess gas from dislodging the bag from the stoma wafer. Using a straight
pin, puncture two holes in the ostomy bag, above the wafer ring. Patient may be
self-conscious about the odor emanating from the vented bag.
8.17.4.2.4. Advise patient to expect an increase in flatus and stool during ascent and
in-flight.
8.17.4.2.5. Peptic ulcer: Monitor H&H and observe for signs of acute GI conditions.
8.17.5. Abdominal distention.
8.17.5.1. Observe for abdominal distention.
8.17.5.2. Ambulate or change positions to relieve symptoms of abdominal distention.
8.17.5.3. If lower abdominal area, have patient roll first from right upper quadrant to left
upper quadrant of abdomen to move flatus.
8.17.5.4. Insert a soft rubber urinary catheter no more than two inches into stoma to
relieve gas buildup. Do not irrigate the colostomy in-flight. Note: Follow surgeon’s
orders for fresh post-op stoma care.
8.17.6. Tube feedings. In the event of altered transportation plans, the ERPS obtains
adequate nutritional provisions for patients, obtains and provides 1-day tube feeding supply
for intra-theater patient movement and three-day supply for inter-theater PM. If on a
continuous feeding, allow for venting.
8.17.6.1. Types of Feeding Tubes.
8.17.6.1.1. [NG/OG] Salem Sump.
8.17.6.1.1.1. Purpose: Diagnostic; gastric decompression/ evacuation;
fluid/nutrient replacement; medication administration.
8.17.6.1.1.2. Management: NG tube is contraindicated in basal skull and nasal
fractures. X-Ray is required to confirm placement.
8.17.6.1.2. Jejunal.
8.17.6.1.2.1. Purpose: Fluid/nutrient replacement; medication administration.
8.17.6.1.2.2. Management: Requires KUB X-Ray placement confirmation
showing the tip is beyond ligament of Treitz either day before or day of transport;
may require simultaneous NG/OG decompression of stomach to prevent
aspiration; may have physician order to position/secure litter head forward
(towards cockpit) with backrest (if not contraindicated) and aspiration for residual
gastric content may not be possible.
8.17.6.1.3. Gastrostomy or Jejunostomy.
8.17.6.1.3.1. Purpose: Fluid/nutrient replacement; medication administration;
DAFI48-107V1 15 DECEMBER 2020 115
decompression/ evacuation.
8.17.6.1.3.2. Management: X-Ray to confirm placement; assess insertion site,
evaluate for leaking or infection (redness, induration (hardness), warmth,
purulence, pain). Note: If feeding tube becomes occluded and irrigation is
unsuccessful, hold feedings and the AECM notifies C2 who then contacts the
governing PMRC for guidance.
8.17.6.2. Management of Feeding Tubes:
8.17.6.2.1. Assess all GI tubes for placement and gastric residual at every patient
care hand-off, every four hours, including during continuous feeding, and before
injecting any fluids or medications:
8.17.6.2.2. Auscultate lung sounds.
8.17.6.2.3. Note distention of the abdomen, presence of bowels sounds, rigid/soft,
tenderness, flatus, bowel movement, and feeding tolerance including nausea,
vomiting and diarrhea.
8.17.6.2.4. Aspirate stomach contents for gastric residual and document amount and
characteristics. Note: Do not discard aspirate (place in drainage bag) allow tube to
gravity drain.
8.17.6.2.5. Administer all tube feedings if gastric residual is less than 50% the hourly
rate or in accordance with physician’s order.
8.17.6.2.6. Hold all tube feedings if gastric residual is greater than 200 ml or greater
than 50% the hourly rate or in accordance with physician’s order. Recheck in one
hour and resume if within normal range. Note: If residual remains above limits after
the second assessment, hold tube feeding and the AECM notifies C2 who then
contacts the governing PMRC for guidance.
8.17.6.2.7. After replacement of gastric contents, medications and bolus feeding add
30-60 ml distilled H2O and allow gravity to clear the tube. Avoid infusing air.
8.17.6.2.8. Clamp the tube for 30-45 minutes to ensure medication absorption before
reconnecting to suction, if ordered. Note: Do not clamp tube for the entire flight;
secure glove/other gravity drainage device if feeding is held or apply suction if
indicated (e.g., nausea; vomiting; abdominal distention; excessive residual posing risk
of aspiration).
8.17.6.2.9. Maintain head of bed/litter elevated at least 45°. Note: If condition
prevents elevation, additional care is taken to prevent aspiration, including holding
feedings 30-60 minutes prior to takeoff and landing. and administering bolus feedings
preferably at cruise altitude to decrease risk of aspiration.
8.17.6.2.10. While in ERPS, oral care is accomplished every two hours with NS or
clean distilled water and includes cleaning/brushing of the teeth and tongue.
8.17.6.2.11. Documentation includes at a minimum tube location (e.g., oral/nasal/J-
G, landmarks, bowel sounds, lung sounds), intake/output, feeding type, GI
assessment, position, oral care, etc.
116 DAFI48-107V1 15 DECEMBER 2020
8.17.6.2.12. VS and temperature and I&O every four hours on the EHR or AF Form
3899.
8.17.6.2.13. Additional feeding tube care/supplies and formula is required for the
destination facility.
8.17.6.2.14. If administration set becomes occluded during transport, change and
prime, then set at the previous administration rate. Note: If feeding tube becomes
occluded irrigation is unsuccessful, hold feedings and the AECM notifies C2 who
then contacts the governing PMRC for guidance.
8.17.7. Motion sickness.
8.17.7.1. Organic motion sickness. Caused by disease processes affecting the inner ear
resulting in sensitivity to labyrinth stimulation.
8.17.7.2. Non-organic motion sickness. Caused by turbulence, hypoxia, fear, emotional
stress, odor, heat, visual stimuli, reactive hypoglycemia, an empty stomach, self-imposed
stresses, dehydration, caffeine, and carbonated drinks.
8.17.7.3. Motion sickness: Preflight/in-flight considerations.
8.17.7.3.1. Assess for signs and symptoms: Headache, apathy, pallor, diaphoresis,
nausea, and vomiting.
8.17.7.3.2. Administer preflight antiemetic as ordered by the VFS 30-60 minutes
prior to flight.
8.17.7.3.3. Medications per AE Clinical Protocol – Over the Counter Medication
Administration.
8.17.7.3.4. Instruct patient to take slow, deep, and relaxing breaths to decrease
anxiety and sympathetic tone.
8.17.7.3.5. Restrict head movements.
8.17.7.3.6. Have patient visually fixate on a stationary object; provide O2 blow by.
8.17.7.3.7. Cool the cabin and/or the patient (cool compresses, open air vents if
available in the mode of transportation). Note: If patient is vomiting, keep NPO, and
consider starting an IV of LR or NS. The AECM notifies C2 who then contacts the
governing PMRC for further instruction and possible orders for intramuscular (IM)
and IV medications if symptoms are severe.
8.17.8. Urinary disorders.
8.17.8.1.1. Barometric pressure changes: May increase nausea and pain from gastric
distention (causing pressure on bladder).
8.17.8.1.2. Decreased humidity: May lead to dehydration.
8.17.8.1.3. Fatigue: Exaggerates underlying condition.
8.17.8.2. Foley catheter/suprapubic catheters/ileal conduit.
8.17.8.2.1. Empty, measure, and document prior to flight.
DAFI48-107V1 15 DECEMBER 2020 117
8.17.8.2.2. Drainage bag needs to be lower than the site to drain properly and not on
the floor. Consider covering drainage bags.
8.17.8.2.3. Document I&O on EHR or AF Form 3899.
8.17.8.3. Nephrolithiasis (renal stone disease)/Urolithiasis (stones in the urinary system).
8.17.8.3.1. Preflight/in-flight considerations:
8.17.8.3.1.1. Pain management.
8.17.8.3.1.2. Anti-emetics.
8.17.8.3.1.3. IVF as needed.
8.17.8.3.1.4. Avoid milk products and encourage fluids per patient’s preference.
8.17.8.3.2. Observe for anuria, hematuria, dysuria, oliguria, and signs and symptoms
of urinary tract infection.
8.17.8.4. Renal failure.
8.17.8.4.1. Preflight/in-flight considerations.
8.17.8.4.1.1. O2 available.
8.17.8.4.1.2. Special diet and fluid restriction as ordered.
8.17.8.4.1.3. Document I&O.
8.17.8.4.1.4. Peritoneal dialysis and hemodialysis may be performed in-flight by
specialty teams, e.g., ERCC.
8.17.8.4.1.5. MTF documents the most recent dialysis and the next scheduled
dialysis.
8.17.8.4.1.6. Peritoneal dialysis; assess site for signs of infection.
8.17.8.4.2. Hemodialysis site - vascular access is present with internal and external
shunts. A “bruit” or a “thrill” may be felt over the blood vessel or tubing and/or
auscultated with a stethoscope. WARNING: Do not flush or use for IV access. Do
not take BP on same extremity as the shunt.
8.17.8.4.2.1. Assess site for infection. Assess distal circulation and neurovascular
status.
8.17.8.4.2.2. Protect access site from cold, pressure, venipuncture, disconnection,
and infection.
8.17.8.4.2.3. Have clamps available for external shunts to control bleeding if
disconnected.
8.18. Obstetrics (OB)/In-Flight Child Birth Management.
8.18.1.1. Decreased partial pressure of oxygen: May cause an increase in cardiac
workload with a decrease in diaphragmatic excursion. Lower concentration of O2 to the
placenta results in fetal hypoxia.
118 DAFI48-107V1 15 DECEMBER 2020
8.18.1.2. Barometric pressure changes: Gas expansion may cause pain and uterine
irritability and decrease capacity for lung expansion. Decreased barometric pressure is
also associated with onset of labor and premature rupture of membranes.
8.18.1.3. Noise/vibration: May increase seizure risk in pre-eclamptic and eclamptic
patients and may cause uterine irritability and excessive stimulation and movement of the
fetus.
8.18.1.4. Decreased humidity: Dehydration may induce or complicate preterm labor.
Pregnant women are also especially prone to dehydration and its effects.
8.18.1.5. Fatigue: Excess weight, physiological changes, overall effects of the
previously mentioned stresses, and the length of time in the AE system fatigues the
patient.
8.18.1.6. G-Forces: May result in pushing fetus onto the maternal vena cava or the
placenta.
8.18.2. General considerations.
8.18.2.1. Patients who are beyond the 34th week of pregnancy are not routinely accepted
for AE but are moved if determined necessary by a physician.
8.18.2.2. Patients in premature labor, or with prematurely ruptured membranes, may be
airlifted after labor is assessed on a case-by-case basis.
8.18.2.3. Patient positioning: If on strict bed rest, patient is positioned in the left lateral
recumbent position. If the patient is placed in the supine position, place a pillow under
either hip to promote uterine displacement and relieve pressure on the inferior vena cava,
which can lead to hypotension and decreased oxygen flow to the fetus. If ambulatory,
seatbelt is placed low on the abdomen across the hips and may be padded with a blanket
or pillow. A litter is available if needed for ambulatory pregnant patients where a back
rest may be used.
8.18.2.4. Pregnant patients are at increased risk of VTE. Hydration is encouraged, seated
patients are encouraged to ambulate and litter patients are encouraged to perform ROM
exercises.
8.18.2.5. Supplies and equipment.
8.18.2.5.1. Universal OB pack.
8.18.2.5.2. Safe to fly approved transport incubator if greater than 34 weeks or
otherwise indicated.
8.18.2.5.3. Oxygen and suction available.
8.18.2.5.4. Doppler or Doptone.
8.18.2.5.5. Pulse oximeter.
8.18.2.5.6. IV infusion pump.
8.18.2.5.7. Cardiac monitor.
8.18.3. Preflight assessment and documentation.
DAFI48-107V1 15 DECEMBER 2020 119
8.18.3.1. Maternal VS including pulse oximetry, temperature, and respiratory rate.

Assess for edema.
8.18.3.2. OB history, including expected date of delivery, gestational age, summary,
current pregnancy course, previous OB history including complications and mode of
delivery.
8.18.3.3. Presence of any signs/symptoms of labor to include duration, frequency, and
intensity of contractions, back pain, pelvic/rectal pressure, or abdominal cramps.
8.18.3.4. Status of membranes: if ruptured, date/time of rupture, amount, and character
of fluid.
8.18.3.5. Presence of vaginal bleeding (amount and any associated pain).
8.18.3.6. Most recent cervical exam.
8.18.3.7. Urinalysis results if indicated.
8.18.3.8. Fetal assessment: Fetal heart tones (FHTs), presentation, last ultrasound
findings, and known abnormalities.
8.18.3.9. Other significant medical history: Epigastric pain, cardiac history, headache,
infectious disease status, medical conditions such as diabetes and hypertension. History
of smoking, alcohol, or drug use in pregnancy.
8.18.4. Treatment/management priorities and in-flight considerations.
8.18.4.1. If gestation is greater than 20 weeks, FHTs are obtained before departure, at
cruise altitude (if possible) and every 12 hours thereafter. If rupture of membranes occur,
FHTs are obtained immediately (ambient noise may make it impossible to hear FHTs).
Normal range for FHTs are 120-160/minute.
8.18.4.2. Obtain maternal VS at cruise altitude and if indicated by a status change.
Maternal oxygenation is particularly important to ensure fetal well-being.
8.18.4.3. Patient comfort may be the greatest concern in stable pregnancies. Comfort
items, hydration/snacks, ambulation, and position change are offered as appropriate.
8.18.5. Considerations for high-risk OB: A qualified MA accompanies high-risk OB
patients.
8.18.5.1. Hypertensive disorders of pregnancy.
8.18.5.1.1. Chronic hypertension: Preexisting hypertension may affect maternal
health, fetal growth, oxygenation, placental function, and predispose patient to other
pregnancy complications.
8.18.5.1.2. Gestational hypertension: Hypertension diagnosed after 20 weeks of
pregnancy not accompanied by other symptoms. May affect maternal health, fetal
growth, oxygenation, placental function, and predispose patient to other pregnancy
complications.
8.18.5.1.3. Pre-eclampsia: Condition generally diagnosed after 20 weeks of
pregnancy. Multi-organ system disease usually evidenced by elevated BP (>140/90),
proteinuria, epigastric pain, visual changes, headaches, and abnormal liver function
120 DAFI48-107V1 15 DECEMBER 2020
tests. HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets) Syndrome:
Variant of preeclampsia characterized by hemolysis, elevated liver enzymes, and low
platelets. The only resolution to preeclampsia is delivery or termination of pregnancy.
8.18.5.1.4. Eclampsia and HELLP Syndrome: Patients with active eclampsia or
HELLP Syndrome are not moved.
8.18.5.2. Placental disorders.
8.18.5.2.1. Placental abruption: Premature separation of normally implanted
placenta. Placental abruption cannot be diagnosed before 20 weeks of gestation.
Cause is unknown although risk factors include hypertension, abdominal trauma,
short umbilical cord, uterine anomaly, cocaine use, and abruption in previous
pregnancy. Signs and symptoms may include abdominal pain or short, frequent
contractions, vaginal bleeding, change in maternal VS or change in fetal heart rate. If
suspected abruption occurs in-flight, patient are treated for hemorrhage/shock and C2
is contacted for guidance and possible diversion to a MTF capable of handling the
situation. WARNING: This is a life-threatening condition for mother and baby.
8.18.5.2.2. Placenta previa: Implantation of placenta in the lower uterine segment,
completely or partially covering the internal cervical os. Placenta previa cannot be
diagnosed before 20 weeks of gestation. Placenta previa may be stable or may result
in episodes of painless vaginal bleeding. If an unanticipated bleed occur in-flight,
treat for hemorrhage/shock and contact C2 for guidance and diversion to a MTF
capable of handling the situation. WARNING: A severe bleed or onset of labor is
life threatening for mother and baby.
8.18.5.3. Preterm labor: Progressive cervical dilation and effacement prior to 37 weeks
of pregnancy. Signs and symptoms may include uterine contractions, back pain, vaginal
discharge or bleeding, rupture of membranes, and pelvic pain. Preterm labor is generally
slowed with medication and mother may be transported to facilitate higher level care for
the premature infant. There are no known effective treatments to stop preterm labor but
may successfully prevent delivery long enough to facilitate transfer. Normally patients
are not transported in active preterm labor.
8.18.5.4. Gestational diabetes: Diabetics diagnosed during pregnancy may be controlled
by a combination of diet, exercise, oral medication and/or insulin. Gestational diabetes
require orders for diet, glucose testing, and medications if needed.
8.18.5.5. Medications used in high risk pregnancy:
8.18.5.5.1. Magnesium sulfate: May be used for seizure prophylaxis in
preeclampsia/eclampsia or for neuroprotection of the fetus in pre-term labor. It is also
used to reduce uterine contractility in pre-term labor.
8.18.5.5.1.1. Magnesium sulfate is a high-risk medication and is always be
administered via infusion pump. WARNING: May produce cardiac arrhythmia,
bradycardia, or cardiac arrest. Stop infusion if chest pain occurs. Contact C2 for
further guidance and possible diversion.
8.18.5.5.1.2. Maternal BP, respirations, strict I&O, and deep tendon reflex are
monitored carefully during magnesium sulfate therapy. Patients may experience
DAFI48-107V1 15 DECEMBER 2020 121
flushing, warmth, dizziness, and malaise as normal symptoms of magnesium

sulfate therapy.
8.18.5.5.1.3. Patients on magnesium sulfate have orders for NPO or fluid
restriction due to the risk of fluid overload.
8.18.5.5.1.4. Magnesium sulfate toxicity: Severe CNS depression and pulmonary
edema may occur. The patient stable on magnesium sulfate and/or serum
magnesium sulfate are measured for therapeutic levels prior to transport. If severe
lethargy, slurred speech, decreased respirations, or other symptoms occur,
discontinue the infusion. Patient is placed on a cardiac monitor prior to
administering magnesium sulfate and calcium gluconate antidote may be
administered per physician order if indicated.
8.18.5.5.2. Tocolytic agents: Terbutaline, nifedipine, indomethacin, and less
frequently, magnesium sulfate may be used for inhibition of uterine contractions.
These medications tend to produce flushing, headache, and tachycardia. Generally,
they are effective in delaying delivery for 24-48 hours.
8.18.5.5.3. Treatment for Magnesium sulfate toxicity.
8.18.5.5.3.1. IV access - central line (preferably) and arterial line/Swan Ganz
(SG) may be present (ensure balloon is deflated in SG prior to takeoff).
8.18.5.5.3.2. Infusion Pumps: Mainline/MgSO4 infusion.
8.18.5.5.3.3. Foley catheter is placed to monitor strict I & O. Note: Consider left
lateral recumbent position when monitoring foley output.
8.18.5.5.3.4. Calcium gluconate for MgSO4 toxicity. Note: Is ordered on the
patient treatment form and provided by the originating MTF. Note: Not a part of
the in-flight medical kit.
8.18.5.5.3.5. Be vigilant for loss of deep tendon reflexes, pulse less than 60/min;
BP less than 90 mmHg/systolic; UOP less than 30cc/hour.
8.18.5.5.3.6. Place on cardiac monitor.
8.18.5.5.3.7. Administer calcium gluconate 10% solution, per physician’s order
(usually 1 gram), slow IVP over three minutes.
8.18.5.5.4. Steroids: Betamethasone injections are typically given to women when
preterm delivery is threatened to promote fetal lung maturity.
8.18.6. In-flight considerations and care for unexpected labor and delivery.
8.18.6.1. Contact C2 for guidance and diversion to a MTF capable of handling the
situation. Request the receiving facility send qualified medical personnel to the aircraft.
8.18.6.2. Patient positioning for in-flight birth.
8.18.6.2.1. If the expectant mother is a litter patient and there is another patient
underneath her, try to move the lower patient to another position. This way you can
facilitate care and privacy.
122 DAFI48-107V1 15 DECEMBER 2020
8.18.6.2.2. If ambulatory, move patient to a litter. Patient may be positioned side-

lying, sitting with her back supported, or whatever position is most comfortable.
8.18.6.2.3. Set up supplies and equipment to include OB pack, doppler, absorbent
pads, and blankets.
8.18.6.2.4. MA or NMA accompanying patient or an AECM reassures the mother to
remain calm and if possible, to avoid pushing until set up is complete.
8.18.6.2.5. Start flowchart: Obtain maternal VS q 1 hour and FHTs q 15 mins.
8.18.6.2.6. Start an IV of LR at 125ml/hour depending on hydration and renal,
cardiac, magnesium sulfate therapy and pulmonary status.
8.18.6.2.7. Administer high flow O2 if needed.
8.18.6.2.8. Delivery procedures: Follow Lippincott or Mosby. In a precipitous
delivery, support baby’s head and body during expulsion and guide baby to the
maternal abdomen. Maternal pushing efforts generally facilitate delivery without any
provider intervention.
8.18.6.2.9. If neonatal resuscitation is required, it is performed by the MA or AECM
in accordance with Neonatal Resuscitation Program Guidelines.
8.18.6.3. Immediate care of the newborn. Infant is dried, stimulated, and placed on the
maternal abdomen. If needed, infant’s mouth and nose may be cleared with a bulb
syringe. Suction the mouth first to avoid aspiration. If sterile scissors are available, cord
may be clamped twice and cut, otherwise cord may be left intact.
8.18.6.3.1. After delivery of placenta, place it in a towel or chux pad and then into a
red biohazard bag with label. If cord is left intact, placenta is placed near and
approximately level to infant. The placenta is offloaded with the patient and not
discarded.
8.18.6.3.2. Breastfeeding is encouraged within the first hour of life to promote
uterine involution and avoid neonatal hypoglycemia. Baby is placed directly skin to
skin with mom and both covered with a blanket to maintain temperature.
8.18.6.4. Labor and delivery and postpartum emergencies - these emergencies require
contacting C2 and diversion to a MTF capable of providing care.
8.18.6.4.1. Shoulder dystocia: Following delivery of the fetal head the fetal anterior
shoulder may become stuck on the pubic bone and baby appears to be turtling.
Delivery of the shoulder is attempted by the mother assuming McRoberts position on
her back (flexion of maternal legs), suprapubic pressure, maternal position change to
hands and knees, and attempting to rotate the fetal shoulders either towards each other
to decrease the shoulder girdle or to rotate the fetus to the oblique to deliver. These
maneuvers are continued until the fetus is delivered or fetal death.
8.18.6.4.2. Breech presentation: A fetus presenting buttocks or feet first may be
delivered vaginally but is at increased risk of injury or cord compression. Allow
maternal pushing efforts to occur and do not attempt to manipulate the baby as the
gentle traction of the baby’s weight provides support and facilitate delivery of the
head. After delivery up to the fetal umbilicus you may assist the delivery of the arms
DAFI48-107V1 15 DECEMBER 2020 123
by sweeping them downward if they do not deliver spontaneously. Following birth,

place the baby on the maternal abdomen to assess and provide routine care.
8.18.6.4.3. Cord prolapse: The umbilical cord precedes the presenting part and
presents a risk of cord compression and hypoxia to the fetus. This is most likely to
occur following rupture of membranes and is suspected if sudden decrease in FHT
occurs with rupture. The cord may be visualized at the introitus or palpated in the
vagina alongside the presenting part. The mother is placed in Trendelenburg or knee-
chest position and the presenting part is lifted off the cord. WARNING: Maintain
this position until fetus can be delivered via cesarean section; do not discontinue until
directed by a physician. If cord prolapse occurs during second stage, baby may be
delivered vaginally before cesarean can be performed. Assess fetal heart tones q 15
minutes. If baby is delivered, place on the maternal abdomen and assess for
resuscitation.
8.18.6.4.4. Postpartum hemorrhage: Blood loss greater than 500 ml following a
vaginal delivery. Patient may experience dizziness, fainting, tachycardia, and
decreased BP. Treatment for hemorrhage is provided along with aggressive fundal
massage. Nipple stimulation may be provided manually or through breastfeeding to
encourage uterine contraction.
8.18.6.5. Documentation.
8.18.6.5.1. For the infant, initiate the EHR or AF Form 3899, AE patient record.
Document time of birth; Apgar score at one- and five-minutes post birth (per
Lippincott); VS; and any concerns with labor. Document no vitamin K or ophthalmic
ointment was given. Add infant to the AF Form 3830, Patient Manifest.
8.18.6.5.2. On mother’s chart, annotate the following: Course of labor; time of birth
in ZULU time (Universal Time); time of placenta delivery ZULU time; fundal
massage and lochia checks; and VS q 15 minutes for 2 hours, then q 30 minutes for 1
hour, then every 4 hours for 24 hours
8.18.6.5.3. Annotate events on AF Form 3829 (TRAC2ES Cover Sheet).
8.18.6.5.4. Annotate events on a JPSR worksheet or DD Form 2852.
8.18.7. A postpartum mother may accompany an infant to more definitive care. Ensure
medication and supplies accompany the patient. If determined to be unstable, the AECM
notifies C2 who then contacts the governing PMRC for guidance and possible diversion to a
MTF capable of handling the situation. If the patient is nursing the infant, all nursing
supplies, breast pump and refrigeration capability is the responsibility of the patient/sending
facility.
8.19. Pediatric Management.
8.19.1.1. Decreased Partial Pressure of Oxygen: Infants and younger children are more
susceptible to hypoxia and become hypoxic earlier than adults.
8.19.1.2. Barometric Pressure Changes: Encourage the use of a pacifier/bottle on
descent to help the infant/child clear their ears. Gastric compression may restrict
124 DAFI48-107V1 15 DECEMBER 2020
diaphragmatic movement, especially if supine; elevate head and consider decompression

with an oral or NG tube if necessary.
8.19.1.3. Thermal: Thermal changes have the greatest impact on infants and young
children who have a very sensitive thermoregulating system. Increase the cabin
temperature, if necessary and possible.
8.19.1.4. Decreased Humidity: Infants and children are more susceptible to dehydration.
If infant is in a safe to fly approved transport incubator, ensure that the proper amount of
distilled sterile water is present in the humidification sponge. If not NPO or receiving IVs
or tube feedings, give fluids at least every two hours. Note: Assess for infant
dehydration: palpate for depressed anterior fontanel.
8.19.1.5. Noise: Infants/children are sensitive to excessive noise. Earplugs are cut in half
(vertically) to fit the smaller ear canals. Infants in a safe to fly approved transport
incubator also wear earplugs, even though the double paned construction muffles aircraft
noise.
8.19.1.6. Vibration: Ensure infants are padded when in car seats or the incubator.
8.19.1.7. Fatigue: Fatigue has the greatest impact on pediatric patients newborn to 12
years old.
8.19.2. General Considerations:
8.19.2.1. Assess airway and breathing: Is the child able to maintain independently or are
adjuncts/assistance to maintain patency required?
8.19.2.1.1. Respiratory dysfunction is the most common cause of cardiac arrest:
stabilization of the airway is of primary concern. Assess rate; mechanics (retractions,
grunting, nasal flaring, use of accessory muscles); chest expansion, breath sounds
stridor, wheezing or paradoxical chest movement.
8.19.2.1.2. Proper positioning is essential because a child’s trachea is narrow, the
tongue is large and intercostal muscles are weak.
8.19.2.1.3. Use jaw thrust or chin lift maneuver to open the airway.
8.19.2.1.4. For spinal immobilization use jaw thrust. WARNING: Hyperextension
or flexion of the neck causes airway compression. A rolled towel placed under the
shoulders of the infant or child aids in maximizing airway size and reducing
resistance. For neutral alignment of the C-Spine, align the external auditory meatus
with the shoulders.
8.19.2.2. If intubated, an MA accompanies the patient capable of managing the airway
and a ventilator.
8.19.2.2.1. Use cuffless endotracheal tubes up to age ten.
8.19.2.2.2. Have on hand one size larger and one size smaller endotracheal tube.
8.19.2.2.3. Monitor pulse oximetry and titrate O2 to maintain SaO2 greater than
93%.
8.19.2.2.4. Ensure adequate humidification of the O2 delivery systems.
DAFI48-107V1 15 DECEMBER 2020 125
8.19.2.2.5. Assess color (pale or cyanotic); capillary refill; skin temperature;

presence of mottling.
8.19.2.2.6. Infants requiring temperature control, apnea monitoring, pulse ox/cardiac
monitor for flight, or ventilator support require an MA.
8.19.2.3. VS: Normal Heart Rate. Count apical pulse for a full minute. WARNING:
Bradycardia is life threatening and is associated with hypoxemia, perform BLS if the
child is bradycardic with poor perfusion or is pulseless.
8.19.2.3.1. Infant: 120 - 160/min.
8.19.2.3.2. Toddler: 90 - 190/ min.
8.19.2.3.3. Preschool: 80 - 110/min.
8.19.2.3.4. School age: 75 - 110/min.
8.19.2.3.5. Adolescent: 60 - 90/min.
8.19.2.4. Normal Respiratory Rate. Count for a full minute. Note: A respiratory rate
greater than 60/min is abnormal for any child.
8.19.2.4.1. Infant: 30 - 60/min.
8.19.2.4.2. Toddler: 20 - 40/min.
8.19.2.4.3. Preschool: 20 - 30/min.
8.19.2.4.4. School age: 18 - 30/min.
8.19.2.4.5. Adolescent: 12 - 16/min.
8.19.2.5. Blood Pressure. Average systolic pressure for children one year old and over:
(Age in years X 2) + 90mm Hg; lower limit: (Age in years X 2) + 70mm Hg indicates
hypotension.
8.19.2.6. Skin Color. Cyanosis is a late sign of hypoxia.
8.19.2.7. Mental Status/Level of Activity: Active and alert? Lethargic or unresponsive?
8.19.2.8. UOP.
8.19.2.8.1. Infant: 2 ml/kg/hour.
8.19.2.8.2. Child over 2 yr: 1 ml/kg/hour.
8.19.2.9. Offer fluids every one to two hours (unless contraindicated). Note: IV infusion
pumps are used for all neonatal/pediatric patients.
8.19.2.10. CNS perfusion: Responsiveness and recognizes parents.
8.19.2.11. Muscle tone.
8.19.2.12. Pupil size, posturing.
8.19.3. Rapid Cardiopulmonary Assessment/Treatment. Reference AHA or equivalent,
TNCC if available, and DHA/J7 Education and Training guidelines. Note: PALS is not
mandatory. If PALS certified, then follow PALS guidelines. If not, practice within the SOC.
126 DAFI48-107V1 15 DECEMBER 2020
8.19.3.1. Early recognition of the symptoms of progressive deterioration in respiratory

and circulatory function and prompt initiation of therapy can often prevent cardiac arrest.
WARNING: Bradycardia is life threatening and is associated with hypoxia; Cardio-
Pulmonary Resuscitation (CPR). CPR is indicated if the child is bradycardic with poor
perfusion or is pulseless.
8.19.3.2. Notify AOC/PMRC for guidance and possible diversion to a MTF capable of
handling the situation.
8.19.4. Assessment of Signs/Symptoms of Severe Respiratory Distress: Notify AOC/
PMRC for guidance and possible diversion to a MTF capable of handling the situation.
8.19.4.1. Respiratory Distress: Respiratory rate over 60 per minute, grunting or forced
expiration, and head bobbing.
8.19.4.2. Retractions: Use of accessory muscles: sternal retractions, chest muscles
visibly pulling and prolonged expiratory time.
8.19.4.3. Nasal Flaring: Obligated nose breathers for the first four months of life. Keep
nares clear of secretions.
8.19.4.4. Cardiovascular: poor peripheral perfusion, tachycardia.
8.19.4.4.1. Neurological: decreased muscle tone, altered mental status.
8.19.4.4.2. Pallor precedes cyanosis. Assess capillary refill (<2 seconds).
8.19.5. Signs/Symptoms Respiratory Distress/Respiratory Failure.
8.19.5.1. Respiratory: Respiratory rate less than 10 per minute and/or irregular
respirations.
8.19.5.2. Cardiovascular: Slower than normal or absent heart rate, weak or absent
peripheral pulses, hypotension.
8.19.5.3. Neurological: Unresponsiveness, limp muscle tone.
8.19.6. Treatment/Management of Respiratory Distress/Respiratory Failure.
8.19.6.1. Airway.
8.19.6.1.1. Assessment: Open airway using the jaw thrust/chin lift maneuver. If neck
injury is suspected, use the jaw thrust. Rule out foreign body, anatomic or other
obstruction.
8.19.6.1.2. Treatment/Management: Place on 100% oxygen via non-rebreather
mask, blow-by if mask is not tolerated. Consider oral airway, nasopharygeal airway,
and intubation per PALS guidelines when operationally feasible. WARNING:
Performed by specially trained healthcare professionals working within their AFSC
scope of practice.
8.19.6.1.3. Breathing.
8.19.6.1.3.1. Assessment: Is breathing ineffective?
8.19.6.1.3.2. Treatment/Management: Rescue breathing either mouth to mouth
or mouth to nose, bag mask, and endotracheal intubation per PALS guidelines
DAFI48-107V1 15 DECEMBER 2020 127
when operationally feasible. Place on pulse oximetry.

8.19.6.2. Circulation.
8.19.6.2.1. Assessment: Heart rate, pulses (central and peripheral), place on cardiac
monitor, capillary refill, and blood pressure.
8.19.6.2.2. Cardiac compressions and fluid resuscitation.
8.19.6.2.2.1. Intravenous access: During CPR in children six years old and
younger, intraosseous access is established if reliable venous access cannot be
achieved within three attempts or 90 seconds, whichever comes first, per PALS
guidelines when operationally feasible.
8.19.6.3. Neurological.
8.19.6.3.1. Minimize anxiety.
8.19.6.3.2. Involve parents.
8.19.6.3.3. Evaluate muscle tone.
8.19.6.3.4. Evaluate pupil size and posturing if present.
8.19.7. Selected diagnosis for the pediatric population.
8.19.7.1. Epiglottitis – a rapidly progressing bacterial infection of the epiglottis and
surrounding soft tissue. Usually effects children between the ages of three and seven
years. Symptoms can mimic croup, but the child is more ill-appearing.
8.19.7.1.1. Signs and Symptoms: Illness or sudden onset (usually six to eight hours
from initial symptom) dysphasia, “barking” cough, inspiratory stridor, hoarse or
muffled voice, fever, or drooling. Child may prefer sitting up or leaning forward.
8.19.7.1.2. Treatment/Management.
8.19.7.1.2.1. WARNING : Do not attempt to visualize/assess the airway or
place anything in the airway.
8.19.7.1.2.2. Minimize anxiety and allow child to choose position of comfort.
8.19.7.1.2.3. Cool mist, blow-by oxygen.
8.19.7.1.2.4. Consider deferring IV access if child is severely agitated. Extreme
agitation and anxiety may result in complete upper airway obstruction.
8.19.7.1.2.5. If IV access is in place, administer fluids, antibiotics and steroids as
ordered.
8.19.7.1.2.6. Acetaminophen for fever. Refer to manufacturer’s recommendations
for dosages.
8.19.7.2. Foreign Body Aspiration - Children between the ages of six months and four
years are at high risk.
8.19.7.2.1. Signs and Symptoms: Sudden onset of coughing or wheezing associated
with an episode of choking.
128 DAFI48-107V1 15 DECEMBER 2020
8.19.7.2.2. Treatment/Management. Reference AHA or equivalent, TNCC if

8.19.7.2.2.1. Severe Distress: Infants – back blows and chest thrusts.
8.19.7.2.2.2. Children – abdominal thrusts.
8.19.7.2.2.3. Minimal to moderate distress – Oxygen with cool mist and IV
fluids.
8.19.7.3. Allergic Reaction – An immediate life-threatening situation. Reference AE
Clinical Protocol – Anaphylaxis.
8.19.7.4. Croup. Croup is a common term for a viral infection that affects the larynx but
may extend to the trachea and bronchi.
8.19.7.4.1. Signs and Symptoms: Barking cough, hoarse or raspy voice, noisy or
labored breathing, rash, eye redness and swollen lymph nodes. May worsen when
awakened from sleep. A history of cold symptoms and fever; wheezing may develop
as a later symptom.
8.19.7.4.2. Treatment /Management: Same as for epiglottitis (reference paragraph
8.19.7.1).
8.19.7.4.3. Primarily supportive. Prevent dehydration and treat respiratory distress.
8.19.7.5. Asthma. The most common chronic illness in the pediatric population is
asthma. Asthma is caused by a variety of environmental and immunologic factors.
8.19.7.5.1. Signs and Symptoms include expiratory wheezing, particularly in an
acute attack; signs of respiratory distress, e.g., retractions, nasal flaring, cyanosis,
accessory muscle use and eventual altered mental status.
8.19.7.5.2. Treatment/Management:
8.19.7.5.2.1. Ascertain history; home medication use; visits to the Emergency
Department or hospital admissions
8.19.7.5.2.2. Supplemental oxygen and beta-adrenergic and anti-cholinergic
aerosols (albuterol and atrovent).
8.19.7.6. Pneumonia. Pneumonia is an inflammation of the pulmonary parenchyma
caused by viral, bacterial, or fungal organisms.
8.19.7.6.1. Signs and Symptoms include fever; grunting respirations; decreased
breath sounds; tachypnea.
8.19.7.6.2. Treatment/Management includes supportive treatment; prevent
dehydration and hypoxia. Treat fever with Tylenol (acetaminophen) per physicians’
order. Administer antibiotics if bacterial in origin.
8.19.7.7. Bronchiolitis and Respiratory Syncytial Virus (RSV). Bronchiolitis and RSV
are common infections of the respiratory tract in children, usually before their second
birthday. For most, it is similar to the common cold, for a small percentage it can lead to
pneumonia and inflammation of the smaller airways of the lungs.
DAFI48-107V1 15 DECEMBER 2020 129
8.19.7.7.1. Signs and Symptoms. Cold like symptoms, runny nose, and cough;
whistling or wheezing; unusually upset or inactive; refusing to eat; and signs of
dehydration.
8.19.7.7.2. Treatment and Management. Treat the symptoms. Use a bulb syringe to
remove mucous; cool-mist vaporizer; offer small amounts of clear fluids and use non-
aspirin fever reducers.
8.19.7.8. Hypothermia. Core temperature below 35 degrees centigrade, or 95 degrees
Fahrenheit. Hypothermia can be caused by both environmental and therapeutic
interventions such as rapid fluid infusion.
8.19.7.8.1. Signs and Symptoms: Clinical signs of hypothermia are subtle: A
change in mental status, cool, mottled skin and shivering in mild to moderate
hypothermia. VS vary with the level of severity.
8.19.7.8.2. Treatment/Management include removing the child from the cold
stresses. Removing wet clothing, warm oxygen, warm fluids, and warm the room.
8.19.7.9. Hyperthermia. Presents with a core temperature of greater than 41 degrees
centigrade, or 105.8 degrees Fahrenheit. Usually seen in children left in hot cars, athletes,
cystic fibrosis.
8.19.7.9.1. Signs and Symptoms: Patients have hot, dry skin; seizures; renal failure.
8.19.7.9.2. Treatment/Management includes remove from the heat stress. Immerse in
cool or iced water, direct fans to increase evaporation.
8.19.7.10. Descent.
8.19.7.10.1. Monitor infant/child closely during actual descent. Encourage the use of
a pacifier/bottle. If allowed to cry during descent, this usually clears the ears.
8.19.7.10.2. Instruct nose-blowing technique for valsalva.
8.20. Mental Health Patient Management.
8.20.1.1. Decreased partial pressure of oxygen and low humidity, may exacerbate the
effects of mental health patients.
8.20.1.1.1. Rule out hypoxia.
8.20.1.1.2. Exacerbates effects of medication.
8.20.1.2. Noise, fatigue, vibration, thermal changes in the aircraft and prolonged
confinement place both physical and psychological stress on patients. Note: With
psychiatric patients, this stress may be manifested by heightened awareness; mood
changes to include increased irritability, depression, apprehension, paranoia, excitability
or worsening suicidal thoughts.
8.20.2. The acute exacerbation of psychiatric or behavioral disorders in-flight may place the
aircraft, crew, other patients, and passengers at risk. If a patient presents a risk to flight
safety, a danger to themselves or others, restraints may be required. The goal is to use the
130 DAFI48-107V1 15 DECEMBER 2020
safest and least restrictive measures to control behavior within the AE environment while
maintaining the patient’s dignity.
8.20.2.1. Physicians, nurses, MAs, and family members may be used to comfort and talk
to the patient.
8.20.2.2. An extra headset from the wireless communication system may be used with
the patient to allow for comfortable speaking, follow HIPAA as implemented by DoDI
6025.18.
8.20.3. Patient classifications (reference paragraph 3.7).
8.20.4. Validation criteria of mental health patients.
8.20.4.1. Look carefully for signs mental health patients may have a change of status
during flight that may directly threaten the aircraft or personnel onboard.
8.20.4.2. The VFS needs to know if the patient is a danger to self, others, or the
aircraft/facility.
8.20.4.3. The AECM may refuse a patient for AE transport if the patient’s behavior is
determined to be detrimental to self and others, the patient has not been adequately
prepared for AE movement, the AE crew is unable to make corrections before departure,
and therapeutic interventions are ineffective. Document in the health record and the
AECM notifies C2 who then contacts the governing PMRC at time of refusal. The
AECM completes and submits a JPSR worksheet or DD Form 2852.
8.20.5. General considerations for mental health patients.
8.20.5.1. Physical factors: Age, cognitive level, sleep patterns, nutrition/hydration,
elimination, touch, comfort, and physical activity. If appropriate based on classification,
allow ambulation, sitting in “get up” seats, “stretch breaks” at en route stops, and comfort
breaks. Offer fluids and nutrition frequently.
8.20.5.2. Pathophysiological factors: Drug interactions, substance abuses, dehydration,
poor nutrition, underlying disease/illness, and metabolic and endocrine disturbances.
8.20.5.2.1. Correct underlying pathology (dehydration; alcohol and drug
detoxification).
8.20.5.2.2. Observe for and treat hypoxia.
8.20.5.2.3. Sedated patients may be more susceptible to dehydration and/or hypoxia,
and aspiration during patient movement.
8.20.5.2.4. Assure adequate hydration and nutrition.
8.20.5.3. Psychological factors: Anxiety/fear, fatigue, depression/grief, denial, boredom,
communication barriers, stress, and post-traumatic stress. Note: History of physical or
sexual abuse may affect individual reactions to physical contact and place the individual
at greater psychological distress. Mental health patients are typically physically healthy
and therefore capable of independent actions that could directly threaten the aircrew,
patient staging personnel and other patients. If the patient is exhibiting aggressive and
uncontrollable behavior, is extremely agitated or violent and/or is determined to be a
danger to flight safety, self, or others, give as needed (PRN) medication as ordered. If no
DAFI48-107V1 15 DECEMBER 2020 131
PRN medication is ordered, give Haldol or Valium in accordance with AE Clinical

Protocol – Acute Exacerbation of Mental Health or Behavior Disorders. Consult with the
PMRC VFS and C2 for guidance and possible diversion to a MTF capable of handling
the situation and for further medical direction as soon as operationally feasible.
8.20.5.4. Environmental factors: Confined space, noise, lighting, positioning,
temperature, aircraft systems, and personal items.
8.20.6. Physician orders for mental health patients.
8.20.6.1. The originating physician writes orders for routine medications as well as PRN
medications for increasing symptoms while the patient is in the AE system.
8.20.6.2. Extremely high-risk mental health patients travel with an experienced
psychiatric technician/RN or medical provider capable of recognizing the need for the
medication administration and/or providing specialized care.
8.20.6.3. The requirement for an MA is determined by the originating physician in
consultation with the PMRC VFS. Note: If operationally feasible, all mental health
patients requiring ongoing supervision have an MA of the same gender and
commensurate rank during movement between the originating and the destination
facility.
8.20.7. Preflight/in-flight care for mental health patients.
8.20.7.1. General:
8.20.7.1.1. Position litter patients in the lowest litter space, away from the flight
deck, emergency exits, and O2 shutoff valves. Assign ambulatory patients a seat near
the bulkhead, away from the flight deck, emergency exits and O2 shut off valves.
Assess potential safety risks of nearby objects and cargo.
8.20.7.1.2. Inform flight crew as to where the mental health patient is placed on the
aircraft and where they are at all times. For confidentiality purposes, no further
information is given.
8.20.7.1.3. Give clear behavioral expectations (examples include seatbelts, no
smoking, stretch breaks, no access to the flight deck, and use of the lavatory) and
establish a verbal contract, including when medication or restraints can be used.
8.20.7.1.4. Use neutral language and speak in a non-threatening, non-judgmental
manner.
8.20.7.1.5. Mental health inpatients and their hand-carried bags will be searched by
an AECM for sharps, matches, lighters and cigarettes prior to enplaning. (T-1). These
items will be inventoried, secured, and deplaned to the receiving MTF. (T-1). Use AF
Form 3854, Receipt for Patient’s Valuables. Litter patients are allowed to carry
eyeglasses, toothbrush, and a small amount of money, wedding band, rings,
wristwatch, ID card, and wallet.
8.20.7.1.6. The designated MA or AECM maintains line-of-sight or one-to-one
observation of patients in restraints and/or with suicidal, homicidal or elopement
precautions. Assign one AECM, preferably the same gender to act as the team leader.
132 DAFI48-107V1 15 DECEMBER 2020
This caregiver coordinates with the AECM and the MA if further interventions are
required.
8.20.7.1.7. Disposable eating utensils do not need to be removed for high-risk
patients but are inventoried when trays are collected.
8.20.7.1.8. Offer fluids every two hours.
8.20.7.1.9. Medications are to be given preflight and PRN if behavior becomes
unmanageable. Monitor SpO2 and temperature for patients on antipsychotic
medications (e.g., risperidone, olanzapine).
8.20.7.1.9.1. Determine whether medication is effective. Document findings.
8.20.7.1.9.2. Body temperature of 102°F and above along with increased
agitation while on antipsychotic medication may indicate neuroleptic malignant
syndrome (NMS) which can be life-threatening. If symptoms appear preflight, the
patient is not stable for flight. The AECM notifies C2 who then contacts the
governing PMRC for guidance. WARNING: If symptoms appear in-flight, hold
medication, monitor VS, apply cooling blanket if available. Assess for increased
agitation, which may require PRN anti-anxiety medication as ordered by the
physician. Document the medication administration; the AECM notifies C2 who
then contacts the governing PMRC.
8.20.7.1.9.3. High potency neuroleptics, such as Haldol, may cause
extrapyramidal symptoms (EPS) within hours or days after starting medication.
EPS may present as muscle spasms or distortion of the neck, jaw, tongue, rotating
of the eyes, or inability to be still. Other side effects may include cardiac
irregularities, hypotension, respiratory suppression, and over-sedation. Patients on
these medications require orders to treat potential EPS. WARNING: If
symptoms appear in-flight and no orders are available, hold neuroleptic
medications, and the AECM notifies C2 who then contacts the governing PMRC
for guidance. Cogentin and Benadryl are available in the in-flight kit (IFK) if
ordered by the VFS. WARNING: If previously untreated EPS symptoms are
present preflight, the patient is not stable for flight.
8.20.8. Acute exacerbation of psychiatric or behavior disorder. If the patient is exhibiting
aggressive and uncontrollable behavior, is extremely agitated and violent, and/or is
determined to be a danger to flight safety, self, or others on the aircraft, administer PRN
medication as ordered. Consult C2 and the PMRC for guidance, medication orders and
possible diversion to a MTF capable of handling the situation. If no PRN medication is
ordered, give Haldol or Valium in accordance with AE Clinical Protocol – Acute
Exacerbation of Mental Health or Behavior Disorders. Consult with the PMRC VFS and C2
for guidance and possible diversion to medical treatment facility (MTF) capable of handling
the situation and for further medical direction as soon as operationally feasible.
8.20.8.1. An AECM trained and competent in the application of restraints acts as the
team leader and coordinates with the MA. The team leader establishes and is responsible
for patient interaction while en route.
DAFI48-107V1 15 DECEMBER 2020 133
8.20.8.2. Inspect short and long restraint belts and wrist and ankle cuffs for cuts, tears, or
excessive wear. Assure there are compatible/operable restraint keys available and the
caregivers know the location of the keys. Prior to takeoff, verify the restraint key opens
the locking device. The patient’s restraints are not attached to or around the litter itself
(reference paragraph 8.20.9).
8.20.8.3. The safest and least restrictive alternative methods for controlling violent and
uncontrollable behavior in the AE environment is utilized. These include but are not
limited to:
8.20.8.3.1. Countermeasures. Appropriate use of medications and/or physical
restraints in AE are used to prevent patients from physically harming themselves,
others, or becoming a safety risk to the flight. The least restrictive methods are used
to maintain safety of the patient, others, and the aircraft. Verbal deescalating
techniques are always used first. De-escalating techniques can include allowing the
patient to verbalize their feelings in an appropriate manner and talking to the patient
in a calm but firm direction. An extremely agitated, high-risk patient may require an
upgraded classification or may need to stay behind. Appropriate standing PRN
medications (PO/IM) is required.
8.20.8.3.2. Verbal de-escalation, verbal contract, explanation of consequences for not
changing behavior, MA/family intervention, and medication as ordered.
8.20.8.3.3. Perform brief examination to rule out and treat underlying organic
medical causes of agitation to include but not limited to hypoxia, hypoglycemia,
alcohol/drug intoxication or withdrawal, medication effect/overdose, and
hypotension.
8.20.8.3.4. Assessment to include but not limited to orientation to time, person and
place, ability to follow commands/recall directions, or accepts limits and reliably
contracts for safety. Identify if a danger to flight safety, increased risk to self or
others, or too agitated/violent and needs sedatives administered. Note: If attempts at
verbal de-escalation have failed and the patient is extremely violent, out of control or
a threat to flight safety, then medicate with prescribed PRN medications and apply
restraints. Call C2 and request a patch to the PMRC if in-flight or call the VFS if in
the staging facility. Note: If this situation occurs prior to takeoff, the patient is not
stable for flight. Stabilize the patient with medication prior to takeoff in coordination
with C2, PMRC, and/or local physician. The mission is not be delayed in order to
meet this requirement.
8.20.8.4. When alternative measures are unsuccessful, the AECM and the MA:
8.20.8.4.1. Ensure the patient, the crew, and others are not in immediate danger.
8.20.8.4.2. Direct the notification of the flight crew to include securing access to the
flight deck.
8.20.8.4.3. Make every effort to maintain the patient’s dignity and privacy.
8.20.8.4.4. Inform the patient and family member (if present) he/she has escalating
symptoms, and the crew is assuming control until he/she is able to regain control.
134 DAFI48-107V1 15 DECEMBER 2020
8.20.8.4.5. If restraints are required, apply in accordance with AFMAN 10-2909 and
follow the AE Clinical Protocol - Acute Exacerbation of Mental Health or Behavioral
Disorders.
8.20.9. Management of patients requiring restraints in the AE environment. WARNING:
When applying physical restraints, there is a potential to produce serious consequences, such
as physical and psychological harm, loss of dignity, violation of an individual’s rights, and
even death.
8.20.9.1. The goal for restraint use is to provide the most effective method to ensure and
maintain the safety of the patient and staff/aircrew. Restraints may also be utilized for
patients at risk for dislodging vital therapeutic devices.
8.20.9.2. Restraints are not applied as punishment or for crew convenience.
8.20.10. Physician written time limited orders for restraints:
8.20.10.1. Physicians annotate restraint orders on the EHR or AF Form 3899. Each order
for physical restraints covers the timeframe the patient is in the AE system. A PRN
restraint order is not a valid order.
8.20.10.2. In an emergency, AECM may initiate the use of restraints before an order is
obtained. The AECM may determine a patient requires restraints or the patient requires
the continuation of restraints in the AE environment beyond initial order. In either
situation, the use of restraints does not exceed 24 hours.
8.20.10.3. Document application, continuation of restraints and clinical observations to
the governing PMRC through C2.
8.20.10.4. After the original restraint order is obtained, the patient receives a face-to-face
assessment by a physician or licensed independent practitioner, usually done at the RON
or destination facility, whichever is sooner.
8.20.10.5. In the AE system, contact C2 when restraints are initiated without an order.
Document all C2 contact attempts/contacts on the EHR or AF Form 3899. Note: In the
AE system contact C2 and PMRC with any change in the patient’s condition and delay of
the time frames below.
8.20.10.6. The following time constraints are ideally required for physician assessment
after initiation of restraints:
8.20.10.6.1. Four (4) hours for adults.
8.20.10.6.2. Two (2) hours for children and adolescents age 9 to 17.
8.20.10.6.3. One (1) hour for patients under age nine.
8.20.11. Level of observation required for restrained patients is direct observation for the
duration of the restraint episode. During the restraint period, the AECM may remove wrist
restraints but not the ankle restraints. This is consistent with maintaining flight safety and
facilitates patient feeding and other personal activities while the patient adapts to the AE
environment.
8.20.12. Documentation of patient in restraints and release criteria.
DAFI48-107V1 15 DECEMBER 2020 135
8.20.12.1. Patient assessment and behavior/justification for PRN sedation medication or

restraint application.
8.20.12.2. Date/time of administration of medication and/or application of restraints, and
outcome.
8.20.12.3. Date/time of notification of the physician.
8.20.12.4. Complete a JPSR worksheet or DD Form 2852.
8.20.12.5. Maintain direct observation, including during takeoff and landing.
8.20.12.6. Perform neurovascular assessment to extremities and document observations
every 15 minutes according to the EHR or AF Form 3899.
8.20.12.7. Assess hydration, nutrition, skin integrity, and toileting needs every two hours
8.20.12.8. Turn and reposition patient at least once every two hours, removing one
extremity restraint at a time to check skin integrity.
8.20.12.9. Perform skin care to the area and ROM exercises at least once every two
hours
8.20.12.10. Leg restraints are not removed while in-flight. During patient staging, if the
patient is reassessed by a physician, the physician may write an order to remove the
restraints.
8.20.13. Alcohol and drug withdrawal.
8.20.13.1. Level of withdrawal is determined according to the Clinical Institute
Withdrawal Assessment for alcohol (CIWA) guidelines (reference Attachment 12).
8.20.13.2. Signs and symptoms may be mild-moderate such as restlessness, agitation,
anxiety, and fear, nausea, vomiting, malaise, weakness, tachycardia, diaphoresis, elevated
temperature, tremors, and dilated but reactive pupils.
8.20.13.2.1. Critical symptoms may include abnormal VS, tremors, seizures, delirium
(fluctuating mental status), and hallucinations.
8.20.13.2.2. A detoxification period of three to five days is required to be accepted
for flight.
8.20.13.2.3. If residual withdrawal symptoms are present, IV access is required.
8.20.13.2.4. Medications per AE Clinical Protocol - Acute Exacerbation of Mental
Health or Behavior Disorders Medication Administration.
8.20.13.2.5. Documentation includes subjective and objective data for giving the
medication; VS; known allergies; for women of childbearing years, date of last
menstrual cycle; date and time of administration and notification of a physician, and
the outcome. The following statement is documented on the EHR or AF Form 3899.
“(Insert name of drug) was administered in accordance with AE Clinical Protocol -
Acute Exacerbation of Mental Health or Behavior Disorders. Complete a JPSR
worksheet or DD Form 2852.
8.20.14. Acute stress disorder/post-traumatic stress syndrome (PTSD).
136 DAFI48-107V1 15 DECEMBER 2020
8.20.14.1. Special consideration are provided to mental health patients experiencing

acute stress reactions and PTSD. Acute stress and PTSD develop after experiencing a
psychologically traumatic event outside the range of usual experience (e.g., combat,
bombings, sexual assault).
8.20.14.1.1. Individuals may re-experience the event through recurrent thoughts,
images, flashback episodes and dreams.
8.20.14.1.2. Individuals may present with symptoms such as increased arousal or
irritability, sleep deprivation, hypervigilance, exaggerated startled response, survival
guilt, poor concentration, anxiety, and motor restlessness.
8.20.14.2. Assess for signs and symptoms (may be associated with other injuries:
Tremors, profuse sweating, dry mouth, tachycardia, shortness of breath and
hyperventilation (rule out hypoxia), irritability, flat affect, staring, crying, insomnia, and
avoidant or emotional numbness). Note: May be more prone to violent and aggressive
behaviors while in the AE environment due to stress of flight.
8.20.14.3. Treatment/Management begins as soon as symptoms are noticed.
8.20.14.3.1. Keep acute stress disorder/PTSD patients together for mutual support
and away from other patients, if feasible. Provide comfort measures to include fluids,
nutrition, blankets, and medications.
8.20.14.3.2. Talk to patients in a calm, reassuring manner, avoid approaching
individual from behind and keep from touching if possible.
8.20.14.3.3. Anxiolytic medications may be necessary preflight and in-flight for
increased anxiety, extreme agitation, and restlessness.
8.20.15. Post-mission/RON requirements.
8.20.15.1. The receiving MA assumes responsibility of the patient and remains with the
patient at all times until released. Restraints remain in place during transportation to the
MTF. Restraints are not placed for the convenience of the receiving facility. Continuity
of care and patient dignity is maintained en route to the receiving MTF.
8.20.15.2. A physician or licensed independent practitioner performs a face-to-face
reassessment of the patient to determine if restraints are to be continued while in the AE
environment.
8.20.15.3. Higher acuity psychiatric patients (e.g., 1A or 1B) or alcohol abuse patients,
or in extreme situations where a patient has required restraints for more than 24 hours, a
RON bed may be required at an off-base psychiatric facility. Notify PMRC personnel of
requirements in the event of unscheduled RON’s.
8.21. Pain Management.
8.21.1.1. Decreased partial pressure of oxygen: Decreases tissue oxygen availability and
exacerbates oxygenation deficiencies due to preexisting hypoxias related to injury,
disease, and/or treatment. May exacerbate the CNS effects of pain medication.
DAFI48-107V1 15 DECEMBER 2020 137
8.21.1.2. Barometric pressure changes: Gas expansion in the abdominal cavity at cruise
altitude may lead to crowding of the diaphragm increasing pain and splinting. Splinting
and diaphragmatic crowding decreases lung volume and expansion and may exacerbate
the risk of hypoxia. Consider placing an NG tube.
8.21.1.3. Thermal: Cold temperatures may lead to vasoconstriction, shivering and
exacerbated pain. Keep patient warm and limit exposure to cold temperatures.
8.21.1.4. Vibration/turbulence: Increases muscle activity, metabolic rate, and peripheral
vasoconstriction. Avoid excessive speed of ground transportation assets. Secure patients
away from the bulkhead and floor of ground vehicles and aircraft, encourage and assist
with position changes, and provide adequate padding and skin care, especially for
orthopedic patients with internal/external fixators.
8.21.1.5. Gravitational forces: Seat belts in side-facing and rear-facing seats may cause
injury during acceleration/deceleration; use extra padding between abdomen and seat belt
for patients with abdominal surgery.
8.21.1.6. Fatigue: Exacerbates the patient’s underlying condition/diagnosis due to the
overall effect of previously mentioned stresses of flight, and length of time the patient has
been in the AE system.
8.21.2. General: Pain is a complex experience with multiple dimensions and is always
subjective. Pain is defined by the International Association for the Study of Pain as an
unpleasant sensory and emotional experience associated with actual or potential tissue
damage or described in terms of such damage. Note: The inability to communicate verbally
does not negate the possibility that an individual is experiencing pain and is in need of
appropriate pain-relieving treatment. Note: Do not give supplemental acetaminophen
(Tylenol) with oral narcotics containing acetaminophen as this may lead to toxicity risks.
8.21.2.1. Undertreated and poorly managed pain may lead to adverse physical and
psychological consequences and complications such as pneumonia, VTE, delayed
recovery and/or progression to chronic pain. Reassessment of pain is required whenever
the patient’s environment changes. Pain management needs change frequently and can
dictate whether transport is possible (or recommended).
8.21.2.2. For any patient with escalating pain control requirements, vigilant monitoring,
and documentation during and after all interventions is mandatory to assess the patient’s
response to therapy and to prevent problems such as oversedation and airway obstruction.
Proper documentation of orders, VS, pulse oximetry monitoring, patient response and a
coordinated hand-off when providers change duties is critical.
8.21.2.2.1. IV pain medications in accordance with AE Clinical Protocol - Pain
Management.
8.21.2.2.2. Phenergan is sedating and when used with opioids may increase the risk
of respiratory depression. Respiratory depression, airway obstruction, and apnea are
much more common when these medications are used in combination. Tolerance to
respiratory-depressant effects usually develop within 1 week of starting regularly
scheduled opioid therapy.
138 DAFI48-107V1 15 DECEMBER 2020
8.21.2.2.3. Benzodiazepines, such as diazepam, clonazepam, or lorazepam, due to

their sedative and respiratory depressant effects, are used cautiously with opioids. The
opioids’ dose may need to be decreased. Respiratory depression, airway obstruction,
and apnea are much more common when these medications are used in combination.
8.21.2.2.4. Frequent monitoring of VS, including Motor Activity Assessment Scale
(MAAS) sedation score, is essential not only when administering the medications, but
for 15 – 30 minutes further to ensure these complications do not occur.
8.21.3. Pain assessment: When assessing pain, always rule out and treat life-threatening
conditions, such as cardiac pain/pulmonary embolism.
8.21.3.1. Indicators of pain by hierarchy:
8.21.3.1.1. Patient self-report – single most reliable measure of intensity of pain.
8.21.3.1.2. Pathological conditions or procedures known to be painful.
8.21.3.1.3. Observed pain-related behaviors (grimacing, restlessness, vocalization,
groaning).
8.21.3.1.4. Reports of pain by family or attendant.
8.21.3.1.5. Physiological changes (increased pulse and BP).
8.21.3.2. Types of pain scales. When choosing a pain scale, select the one that best aligns
with the age and condition of the patient (reference Attachment 13).
8.21.3.2.1. 0-10 Numeric Pain Rating Scale.
8.21.3.2.1.1. Most commonly based on a scale from zero to 10.
8.21.3.2.1.2. Zero represents no pain at all while 10 represents the worst
imaginable pain.
8.21.3.2.2. Wong-Baker faces.
8.21.3.2.2.1. Represented by faces with expressions. Zero is represented by a
smiley face, while 10 is represented as a distraught, crying face.
8.21.3.2.2.2. Useful when rating pain in children, or for adults with mild
cognitive impairments.
8.21.3.2.3. Defense and Veterans Pain Rating Scale. This scale includes visual cues
and verbal descriptors to improve interpretability of incremental pain intensity levels
supplemental questions assess pain interference with general activity, sleep, mood,
and stress.
8.21.3.2.4. Face, Legs, Activity, Crying and Consolability (FLACC). Observer rated
pain scale for children between the ages of two and seven and for people who are
unable to communicate their pain (e.g., ventilator patients).
8.21.3.3. Obtain VS (including pulse oximetry) and assess pain at least every four hours
for patients who require en route pain medication administration. Rule out hypoxia and
consider compartment syndrome.
DAFI48-107V1 15 DECEMBER 2020 139
8.21.3.4. Determine characteristics of pain: Quality, region, radiation, what

provokes/triggers (movement/dressing changes/deep breathing and coughing),
palliates/eases (repositioning/elevation/support/medication), and the adequacy/adverse
effects of pain medication.
8.21.3.5. Ascertain the patient’s pain level and their acceptable level of pain. The
acceptable level of pain is the level of pain the patient can tolerate. Note: Individual
practice may lead to differences in delivery of pain medication. Note: Healthcare
providers’ bias, prejudice and stereotyping may lead to differences in delivery of pain
medication. Avoid attributing pain to psychological causes, and respect/accept patient’s
self-report of pain.
8.21.3.6. If appropriate, educate the patient on the availability of medications.
8.21.3.7. A pain score of three or more usually indicates the need for pain medication.
Assess current medications to evaluate potential interactions to include hypoxia before
administering pain medication.
8.21.3.8. Pain is reassessed as ordered and after interventions.
8.21.3.8.1. Pain and VS are reassessed 15-30 minutes after pharmacologic
interventions.
8.21.3.8.2. Take into consideration the type of medication, time of onset based on
route, and duration of known effectiveness.
8.21.3.9. When operationally feasible:
8.21.3.9.1. Assess cultural attitudes, stoicism, guilt, potential frustration,
helplessness, mental functioning, mood, and fear of pain.
8.21.3.9.2. Educate patients, family, and attendants regarding reporting pain,
availability of pain medication, as well as the low risk of addiction from long-term
use and/or high doses of medication for pain relief, and document in the health
record. Note: Include information about PRN medications being available around-
the-clock.
8.21.4. Pain: Treatment/management:
8.21.4.1. Administer pain medication, as ordered, prior to potential painful events such
as transportation movement and en route staging treatments and dressing changes. Take
into consideration the type of pain medication, time of onset based on route, and duration
of known effectiveness. For example, opioid analgesic onset is immediate when
administered intravenously, and rapid when administered via intramuscular and oral
routes (approximately 30 - 60 minutes); duration is usually one to eight hours. Also
consider adjunct medications such as anxiolytics. Note: Document all known allergies in
the health record.
8.21.4.2. Assess adequacy of pain medication at all patient care hand-offs, en route
staging locations and in-flight. Consider medication for breakthrough pain (pain that
occurs in between regularly scheduled doses of pain medication). Start pain control at
least 60 minutes prior to patient movement from bedside (en route to aircraft) when
feasible. Note: If medication is inadequate or absent at the staging facility, the physician
140 DAFI48-107V1 15 DECEMBER 2020
evaluates the patient and orders pain medication prior to continuation of PM. Note: If a
physician is not present and pain medication is not available or is insufficient, request and
establish contact with PMRC for a physician order.
8.21.4.3. Non-drug interventions to assist in alleviating pain: Maintain body alignment,
elevate extremity, change position; readjust splints and bivalved casts; encourage
physical activity, if operationally and clinically feasible. Consider heat/cold application if
not contraindicated.
8.21.4.4. Prescribed controlled medications entrusted to a patient/attendant are
considered the property of the individual, who is then responsible for safeguarding and
administering the drug(s) during all phases of PM. Ensure patients understand use and
have an adequate supply for duration of movement to the receiving MTF. Medical
personnel determines if the patient or attendant is competent to safely manage these
medications. Note: Patients and NMA do not carry or administer controlled medications
without a current written physician’s order.
8.21.4.5. The originating facility supplies the patient’s pain medication for their time in
the AE system. Intratheater requires a 1-day supply and intertheater requires a three-day
supply of medication.
8.21.5. Epidurals and PNBs.
8.21.5.1. Epidural analgesia and PNBs are a proven adjunct for severe pain management
for patients transiting the continuum of care. Patients are managed by ERCC team, MAs,
and/or AECMs and ERPS personnel. All active staging facility nursing personnel
accomplish the approved AMC/SG training plan annually. All other ERPSS personnel
completes the training within 90 days of deploying to an active patient staging location.
This training is documented in the RN‘s competency assessment folder and the medical
technician Air Force Training Record. The CNE is responsible for ensuring all staging
facility nursing personnel have accomplished training prior to caring for patients with
PCA/PNB or epidural analgesia. The training is located on the AMC SG/A3 website.
8.21.5.2. The following apply to patients moving in the AE system without an
attendant/ERCC team:
8.21.5.2.1. An epidural analgesia or PNB infusion will be in place and running
without incident for a minimum of 4 hours prior to departing the sending facility. (T-
2).
8.21.5.2.2. Only analgesic concentrations of local anesthetics are infused via
epidural. Narcotics (or any other medication) are NOT be added to the epidural
infusions.
8.21.5.2.2.1. Only amides such as bupivacaine and ropivacaine are used. Esters,
such as procaine and chloroprocaine are not permitted due to increased risks
associated with these medications.
8.21.5.2.2.2. More dilute solutions, e.g., 0.125% Bupivacaine, are used to
decrease the risk of sympathetic blockade.
DAFI48-107V1 15 DECEMBER 2020 141
8.21.5.2.3. All infusions are stable at an analgesic level, not a surgical anesthesia
level, at the T10 dermatome (umbilicus) level. The patient is then able to regain
partial “motor” control of the lower extremities.
8.21.5.2.4. Other pain medications or narcotics may be administered orally,
intravenous (IV) or by PCA using established protocols or in conjunction with written
physician orders.
8.21.5.2.5. All epidural analgesia or PNB infusions are administered using an
approved infusion pump. Non-approved pumps require a waiver from AMC/A3VM.
The pump and the IV tubing is labeled as “EPIDURAL INFUSION” or
“PERIPHERAL NERVE BLOCK INFUSION.”
8.21.5.2.6. A patient hand off is completed and documented on the EHR or AF Form
3899 each time a different clinician accepts care of the patient. The hand-off is
performed consistently with high alert IV medications to prevent programming errors.
An independent double-check is defined as two medical persons familiar with the
process/equipment/medication (at least one being a RN), independently verifying the
practitioner’s/provider’s orders, medication hanging, and the correct set up of PCA or
IV pump in use (rate, dose, volume to infuse, medication concentration, basal rate,
bolus lockout, etc.). This hand-off includes a review and documentation of history on
the infusion pump. Documentation of double checks are reflected by two signatures
on required forms/flow sheets or in the health record. This is applicable to MTFs,
ERPS, ERCC team, and AECMs. Double-checks are conducted and documented
when initiating high alert medications, during hand-offs of care, following a change
in orders, and when a new bag is started. The only time total volume remaining is
changed is when medication bags are replaced.
8.21.5.2.7. Sufficient orders for the epidural analgesia or regional block infusion are
fully documented in the health record. These orders include the medication, infusion
rates/settings as well as back-up pain management orders if the pump should fail, or
inadequate pain relief occurs while the patient is in transit.
8.21.5.2.8. In the event there are complications related to the epidural infusion or
regional block, nursing personnel terminates the infusion and treats the patient as
appropriate and per established clinical guidelines established by AMC/SGK.
Interventions could include a range of activities from administering alternate pain
adjuncts to airway/circulatory support. Changes in status and interventions are
documented in the health record and communicated to C2 who then contacts the
governing PMRC.
8.21.5.2.9. At each en route location, an anesthesia provider is contacted, if needed,
for consultation.
8.21.5.2.10. Sterile dressings to insertion site are not changed in the aircraft. They
may be reinforced if necessary. The epidural catheter is secured so the catheter is not
stretched or pulled at the site with any movement of the patient.
8.21.5.3. At each patient care hand off and every two hours, assess pain status, MAAS
sedation score, dermatome level of analgesia, VS, motor function, and drug side effects.
142 DAFI48-107V1 15 DECEMBER 2020
8.21.5.4. Assessing motor/sensory dermatome levels includes motor and sensory

function checks. Note: a dermatome is best defined as that area of the skin that is
supplied by a single spinal nerve or more specifically, the vertebral level at which the
spinal nerve exits the spinal cord that innervates the skin in a contiguous sensory band or
stripe (~ 1-2 inches wide). These bands arise posteriorly, from the spinal column
laterally/anteriorly. Each stripe or band is referred to as a dermatome and each
dermatome corresponds to a specific nerve root. Dermatome segments are standardized to
a specific nerve root and enable clear/consistent communication about the level of
anesthesia (sensory blockade).
8.21.5.4.1. Assessing motor function:
8.21.5.4.1.1. Ask patient to wiggle toes, dorsiflex foot.
8.21.5.4.1.2. Ask patient to bend knees/raise leg.
8.21.5.4.1.3. Tense the rectus muscles by lifting the head.
8.21.5.4.2. Reference Figure 8.1 to determine the level of motor blockade.
DAFI48-107V1 15 DECEMBER 2020 143
Figure 8.1. Dermal Segmentation (Dermatome Map).
8.21.5.4.2.1. Above Figure 8.1 Supplied by American Society of

Electroencephalography Technicians (ASET), 2011.
144 DAFI48-107V1 15 DECEMBER 2020
8.21.5.5. Assessing sensory function: Note: Positive findings indicate return of motor
function. It does not, however, indicate resolution of the sensory/autonomic blockade
therefore adequate pain control may still be present.
8.21.5.5.1. Temperature - use a cold object (e.g., ice/alcohol swab).
8.21.5.5.2. Touch - apply a sharp and dull object to the skin (e.g., paper clip).
8.21.5.5.3. Begin the assessment along the sternum moving from side to side,
progressing downward until the patient identifies a 'change' in ‘touch’ sensation and
‘temperature’ sensation (cold warmth or no sensation). Sensation levels may return
faster on one side than the other, therefore clear documentation identifying the
sensory levels (left and right) is documented.
8.21.5.6. Peripheral nerve blocks.
8.21.5.6.1. There are several types of regional anesthesia currently used including
axillary, femoral, and popliteal PNBs. With these blocks, the anesthesia provider
injects or infuses the local anesthetic into the tissue surrounding the nerve. Needle
placement is determined initially by using anatomic landmarks. Next, a peripheral
nerve stimulator is used to facilitate precise location of the appropriate nerve. The
anesthetic effect occurs primarily distal to the injection sites. For example, a popliteal
block may be used for distal surgical procedures, such as the achilles tendon repair. In
contrast, intravenous (Bier) nerve blocks are administered distal to the surgical site
and rely on diffusion rather than direct injection to achieve anesthetic effects.
8.21.5.6.2. All local anesthetic agents used in PNBs induce physiologic responses via
the same mechanism. Specifically, anesthetics interfere with the neuronal
membrane’s permeability to sodium. Disruption of sodium exchange results in
inhibition of neuronal impulses between the affected extremity and the brain.
Consequently, sensory, motor, and sympathetic neural pathways are affected, and the
patient is unable to feel or move the anesthetized limb.
8.21.5.6.3. Signs of systemic toxicity include tinnitus, sudden metallic taste,
confusion that progresses rapidly to loss of consciousness, seizures, and abrupt onset
of cardiac dysrhythmias. Neurologic symptoms are likely to appear before
cardiovascular disturbances unless epinephrine (EPI) has been added to the block.
Inadvertent systemic administration of anesthetic combinations containing
epinephrine cause transient tachycardia and hypertension (reference AE Clinical
Protocol - local anesthetic toxicity [LAST] Treatment).
8.21.5.7. Patient care responsibilities for epidural/PNB infusions.
8.21.5.7.1. Ensure the patient is on continuous pulse oximetry for epidurals. Assess
and document the respiratory rate and oxygen saturation, MAAS sedation score, VS,
pain scale, dermatome level, motor and sensory function and side effects (if present)
every 2 hours Document this on the EHR or AF Form 3899. AETs may perform these
duties in accordance with their Career Field Education and Training plan (CFETP).
The AET reports these VS to the FN. If the oxygen saturation falls below 92%
(reference AE Clinical Protocol – Emergency Oxygen).
DAFI48-107V1 15 DECEMBER 2020 145
8.21.5.7.2. Some motor weakness in patients undergoing epidural analgesia or PNB

therapy to a lower extremity is expected and the patient is considered a risk for falls
and requires assistance when ambulating. Identify the patient as a fall risk via the
“Epidural Patient” or “PNB patient” wrist band.
8.21.5.7.3. Assess the dressing for leakage every four hours and record on the EHR
or AF Form 3899.
8.21.5.7.4. Catheters are not removed until reevaluated by an anesthesia provider at
the next scheduled en route stop. Only an anesthesia provider removes the catheter if
required. Staging facility personnel and AECMs never remove the catheter.
Administration of PRN medications per physician’s orders are administered for pain
management if the approved AE infusion pump is turned off due to adverse side
effects.
8.21.5.7.5. Caution is taken with any patient receiving epidural or PNB analgesia via
an indwelling catheter who is also receiving anticoagulation therapy, to include
coumadin, heparin infusions, or low molecular weight heparin or lovenox.
8.21.5.7.6. Maintain IV access of #20 gauge or larger.
8.21.5.7.7. Change epidural/PNB medication bag before infusion runs out.
8.21.5.7.8. Ensure the approved AE infusion pump and IV tubing is labeled
“EPIDURAL ANALGESIA OR PERIPHERAL NERVE BLOCK” and the catheter is
taped with label indicating "FOR EPIDURAL ANALGESIA or PERIPHERAL
NERVE BLOCK USE ONLY." The patient’s placement on the aircraft is clearly
marked on the load plan and specifically identified to the AE crew during pre-mission
crew brief.
8.21.5.7.9. Adverse effects of local anesthetics typically occur as a result of high
blood levels of the drugs and are similar among all agents in use. Neurologic
symptoms are likely to appear before cardiovascular disturbances unless epinephrine
has been added to the block. Inadvertent systemic administration of anesthetic
combinations containing epinephrine causes transient tachycardia and hypertension.
Hypersensitivity, or allergic reactions, although rare, are also a concern with regional
anesthetic agents, and are more likely to occur with ester-based agents than with
amides. Esters include procaine, chloroprocaine, tetracaine, and piperocaine, whereas
amides include bupivacaine, mepivacaine, and prilocaine. WARNING: For all
problems related to these infusions during flight, terminate the infusion (turn off the
approved AE infusion pump) and resort to other established pain management
techniques.
8.21.5.7.10. While controversy exists regarding the mechanism of lipid rescue, the
most accepted theory is that Intralipid creates a new intravascular lipid compartment,
or “lipid sink,” that increases the volume distribution of lipophilic drugs. Distribution
of drugs to this additional lipid compartment rapidly decreases the concentration of
overdosed medicines on vital organs and quickly reverses the effects of the toxins.
Thus far, lipid rescue has been proven to work in anesthetic overdoses of commonly
used emergency department [ED] anesthetics such as bupivacaine and lidocaine
(reference AE Clinical Protocol – LAST).
146 DAFI48-107V1 15 DECEMBER 2020
8.21.5.7.11. If in-flight, notify the VFS (via phone patch) for:

8.21.5.7.11.1. CNS symptoms.
8.21.5.7.11.1.1. Metallic taste in the mouth.
8.21.5.7.11.1.2. Tinnitus.
8.21.5.7.11.1.3. Tingling of the lips; difficulty swallowing.
8.21.5.7.11.1.4. Agitation.
8.21.5.7.11.1.5. Seizures.
8.21.5.7.11.2. Cardiovascular symptoms.
8.21.5.7.11.2.1. Bradycardia.
8.21.5.7.11.2.2. Decreased myocardial contractility.
8.21.5.7.11.2.3. Atrial-ventricular block.
8.21.5.7.11.2.4. Vasodilation.
8.21.5.7.11.2.5. Ventricular arrhythmias.
8.21.5.7.11.2.6. Cardiac Arrest.
8.21.5.7.11.3. Respiratory symptoms.
8.21.5.7.11.3.1. Shortness of breath.
8.21.5.7.11.3.2. Dizziness or light-headedness.
8.21.5.7.11.3.3. Respiratory rate of 10/minute or less, or 50% below baseline.
8.21.5.7.11.4. Patient expressions of impending doom.
8.21.5.7.11.5. Pain out of proportion to injury or out of character for the patient’s
history.
8.21.5.7.11.6. Increasing MAAS sedation score or presence of confusion.
8.21.5.7.11.7. Inadequate analgesia.
8.21.5.7.11.8. Pruritus or nausea/vomiting unrelieved after initial treatment.
8.21.5.7.11.9. Oxygen saturation less than 92% on room air.
8.21.5.7.11.10. Hypotension: Postural BP drop > 15mmHg from baseline.
8.21.5.7.11.11. High sensory level: Numbness at or above nipples.
8.21.5.7.11.12. Motor blockade: Inability to bend knees while lying bed.
8.21.5.7.11.13. Dislodgement or Leakage on the catheter dressing.
8.21.5.7.11.14. Catheter disconnection.
8.21.5.7.11.15. Temperature >101 F and/or presence of shaking chills.
8.21.5.8. Documentation includes subjective and objective data for giving the
medication; VS; known allergies; for women of childbearing years date of last menstrual
DAFI48-107V1 15 DECEMBER 2020 147
cycle; date and time of administration and notification of a physician, and the outcome.
Document the rate (ml/hour), and dose (ml) with VS on the EHR or AF Form 3899 every
two hours. The following statement is documented on the EHR or AF Form 3899 “(Insert
name of drug) was administered in accordance with AE Clinical Protocol - LAST.”
Complete a JPSR worksheet or DD Form 2852.
8.21.5.9. Epidural analgesia therapy and PNB therapy to a lower extremity can cause
motor weakness and is normal; therefore, the patient requires assistance with all
activities. The staging facility nurses and FNs will be responsible for assessing the
patient’s motor strength. (T-0). If a patient cannot move their legs due to excessive motor
block from the infusion, notify the VFS immediately.
8.21.5.10. If the patient has a MAAS score of less than two or greater than four, consider
other causes like hypoxia, pain, and the need to use the restroom, etc. and the AECM
notifies C2 who then contacts the governing PMRC.
Table 8.11. Motor Activity Assessment Scale (MAAS) Sedation Scoring System.
0 Unresponsive Does not move with noxious stimuli
(e.g., suctioning or five seconds of
vigorous sternal or nail bed pressure)
1 Responsive only to noxious Opens eyes, raises eyebrows, turns
stimuli head towards stimulus or moves limbs
with noxious stimuli
2 Responsive to touch or name Opens eyes, raises eyebrows, turns
head towards stimulus or moves limbs
when name is spoken loudly
3 Calm and cooperative No external stimulus required to elicit
response, movements purposeful,
follows commands
4 Restless and cooperative No external stimulus required to elicit
response AND patient is picking at
sheets or tubes OR uncovering self and
follows commands
5 Agitated No external stimuli required to elicit
response AND attempting to sit up OR
move limbs out of bed AND does not
consistently follow commands
6 Dangerously agitated, No external stimuli required to elicit
uncooperative response AND patient is pulling at
tubes or catheters OR thrashing side-
to-side OR striking at others OR trying
to climb out of bed AND does not calm
down when asked
8.21.5.11. If pain medication is not available or is insufficient, request and establish
immediate radio communication with C2who notifies governing PMRC for a physician
148 DAFI48-107V1 15 DECEMBER 2020
order. The AECM completes a JPSR worksheet or DD Form 2852 and document the
occurrence on AF Form 3829 if flight related.
8.21.6. Patient controlled analgesia.
8.21.6.1. Various pieces of PCA equipment/pumps for the administration of pain
medication may be encountered in the AE system. Refer to specific equipment manuals
contained in the EFB or at the patient staging location. WARNING: In addition to
correct labeling of IV and pain medication containers/bags, ensure all IV and pain
management tubing is taped/labeled with drug/location/date/time in ZULU. For example,
“PCA IV Morphine, Right Forearm, Date/ZULU time.” Ensure all medical personnel
lock the PCA pump after set up, dose change, and hand off.
8.21.6.2. Prior to flight. Anesthesia services/pain service personnel:
8.21.6.2.1. Provides consultation and programming of the PCA infusion pump at the
MTF for all patients transiting the AE system, including during ERPS RON.
8.21.6.2.2. Orders and/or reviews all pain medication loading dose(s), PCA bolus
dose amount, lock-out interval, basal flow (continuous) rate, breakthrough pain
orders, continuous peripheral IV infusion or saline lock, and over-sedation protocol
on the EHR or AF Form 3899.
8.21.6.2.3. After confirming infusion programming, the pump and narcotic reservoir
are placed in the protective casing (if available) and locked. Note: Assure pain
management tubing is taped/labeled with drug/location/date/time in ZULU.
8.21.6.2.4. Considers increasing the dose or decreasing lock-out interval to account
for increased pain during patient transport.
8.21.6.3. At each patient care hand-off (e.g., aircraft/ERPS/MTF) and/or “Change of
Shift”:
8.21.6.3.1. Assess pain score, VS, pulse ox, and MAAS baseline score every two
hours. Treat pain PRN. Assess for the presence of medication side effects (nausea,
pruritus, constipation). Note: While on PCA, have continuous pulse ox monitoring as
indicated by patient condition.
8.21.6.3.2. Inspect the PCA narcotic reservoir bag for adequate supply of medication
for the duration of the transport and verify tubing label location. Note: Assess every
two hours and assure tubing and pump are secured to the patient.
8.21.6.3.3. Document and verify pump infusion history and current configuration
with the sending/receiving nurse or MTF representative and annotate remaining fluid
(ml’s) on the EHR or AF Form 3899. The only time total volume remaining is
changed is when medication bags are replaced.
8.21.6.3.4. Confirm with the sending/receiving nurse or MTF representative:
Physician orders, to include any medication loading dose(s), PCA bolus dose amount,
lock-out interval, basal flow rate, over-sedation protocol and breakthrough pain
orders. Also confirm tubing is labeled with date initiated/last changed, and the tubing
is secured.
8.21.6.4. While en route, at RON location or ERPS.
DAFI48-107V1 15 DECEMBER 2020 149
8.21.6.4.1. Document amount of PCA medication administered for each leg of the
mission/patient care hand-off and/or shift change in the EHR, on the EHR or AF
Form 3899.
8.21.6.4.2. If unresponsive to painful stimulation and/or respirations are 10 or less
per minute, stop PCA pump infusion immediately (reference AE Clinical Protocol -
Narcotic or Benzodiazepine Overdose). The AECM notifies C2 who then contacts the
governing PMRC. If in the ERPS, notify anesthesia and/or flight surgeon. Document
all assessment data and follow-up in the patient health record and a JPSR worksheet
or DD Form 2852.
8.21.6.4.3. If the PCA infusion pump is discontinued, the unused volume of narcotic
in the reservoir bag, 2 medical personnel witness and dispose it. One of the medical
personnel is an RN and the amount is documented as “wasted” on the EHR or AF
Form 3899.
8.21.6.4.4. If the pump malfunctions or is emptied or if the catheter is dislodged
(leaking), shut the pump off and provide alternate pain medication. Document in the
health record (if in-flight document on the EHR or AF Form 3829) and submit a
JPSR worksheet or DD Form 2852.
8.21.6.5. Discontinued pumps are returned to the nearest PMI center in accordance with
current CONOPS/OPLAN.
8.21.6.6. Patient/family education.
8.21.6.6.1. Benefits of the pain control system (basal rate, extra dose delivery).
8.21.6.6.2. Safety mechanisms/operation of pump including administration, alarms,
and signals.
8.21.6.6.3. Administration of the pain medication is to be completed by only the
patient due to possible adverse reactions if initiated by others.
8.21.6.6.4. Utilize the AF Form 3899N, Patient Movement Pain Adjunct Flow sheet
to document adjunct pain therapies, pain management and patient handoffs.
8.22. Medications.
8.22.1. Ensuring every patient has an ample medication supply to meet their individual
requirements throughout the patient movement system is the responsibility of every care
provider at every hand-off location. Variables such as the patient's inpatient or outpatient
status, the geographic location, and the capability of the originating and final destination
MTF, along with patient safety, is considered when determining the required amount of
medications. The general intent is to minimize the logistical demand on deployed locations
while meeting medication requirements for all patients en route to their final destination
MTF and/or follow-up outpatient appointment.
8.22.2. Providers use electronic order entry for prescriptions whenever available, in
accordance with AFI 44-102, Medical Care Management.
8.22.3. Inpatients receive controlled substance medications from the IFK or patient staging
facility narcotics, when available. MTF’s will send those medications not maintained in the
in-flight kit. (T-1). MTFs are not required to send a supply of those medications available in
150 DAFI48-107V1 15 DECEMBER 2020
the IFK. If the inpatient is be traveling via CAA, MTFs checks with the PMRC arranging
transport to determine what medications need to accompany the patient. Staging Facility
patient care providers and AECMs are responsible for the accounting and administration of
all controlled and non-controlled medications prescribed to inpatients.
8.22.4. Self-administration of medications (SAM) patients.
8.22.4.1. An outpatient may carry their own supply of controlled substances, if
determined by the sending provider to be competent to self-medicate and when
designated by the VFS. Note: Outpatient mental health patients (5C) are cleared to self-
medicate after consultation by a provider licensed or credentialed in Mental Health.
8.22.4.2. When a patient is allowed to self-administer his/her own medications, AECMs
do not have to count them and those medications remain under the patient’s control.
Medications are prescribed, dispensed, and accounted for by the dispensing pharmacy.
8.22.4.3. Qualified health care providers counsel the patient with instruction and
information regarding their prescribed medication. Education is documented in the health
record.
8.22.4.4. Patients who self-administer their medications ensures the medications are not
stored/kept where other individuals have access to them and are not left in their checked
bags.
8.22.4.5. Prior to flight, an AECM personally interacts with the patient to verify the
patient’s understanding and knowledge, and provide additional education, as appropriate,
on proper SAM. This process begins with the ERPS/MTF and continues throughout the
AE system.
8.22.4.6. Healthcare professionals remain cognizant of potential abuse and misuse of
controlled medications. Outpatients deemed compliant and competent to self-medicate
may carry and administer their own supply of controlled and non-controlled medications
if the following is clearly documented on the EHR or AF Form 3899.
8.22.4.6.1. Provider’s order for “SAM.”
8.22.4.6.2. “Will self-medicate” boxes are marked on the front and reverse of the AF
Form 3899 or EHR equivalent.
8.22.4.6.3. The following statement written and signed by the verifying provider or
nurse stating the patient is compliant and competent to self-medicate: “Patient is
hand-carrying medication(s); has been instructed on self-administration of (list
medication name[s]) and verbalizes understanding.”
8.22.4.6.4. At a minimum, SAM patients are reassessed at every hand-off for
continued competency and compliance.
8.22.4.6.5. SAM patients do not require a medication administration record (MAR)
to be completed unless medication is administered in accordance with an AECP or
out of the AE in-flight kit allowance standard.
8.22.4.7. If an outpatient is not compliant and/or not competent to SAM at any point of
the movement process, the respective care provider (e.g., AECM or ERPS personnel):
DAFI48-107V1 15 DECEMBER 2020 151
8.22.4.7.1. Immediately assumes responsibility for and administration of that

patient’s medication(s).
8.22.4.7.2. Clearly documents the change in the patient’s SAM status on the EHR or
AF Form 3899.
8.22.4.7.3. Verbally communicates changes in status to the accepting care provider at
the next patient hand-off.
8.22.4.7.4. Initiates a JPSR worksheet or DD Form 2852.
8.22.4.8. MTFs at en route stops refill the controlled substance as required for onward
movement. This reduces excessive quantities of controlled medications being moved
through the PM system. All medication is appropriately labeled with the patient’s name
and directions for administration by the sending facility.
8.22.4.9. Deployed locations send a 1-day supply for patients moving from a Role 2 to a
Role 3 facility in the combat operations theater and a two-day supply for patients moving
from the Role 3 to the Role 4 medical center (reference JP 4-02).
8.22.5. Medication quantities required for PM.
8.22.5.1. Outside the continental United States (OCONUS) to CONUS PM.
8.22.5.1.1. Inpatients moving directly from an OCONUS MTF to port of entry
accepting MTF/final destination require a two-day supply (e.g., Landstuhl Regional
Medical Center [LRMC]) to Walter Reed National Military Medical Center.
8.22.5.1.2. Inpatients moving from an OCONUS MTF to port of entry ERPS, RON
and then move on to accepting MTF/final destination require a three-day supply (e.g.,
LRMC to Andrews ERPS to Fort Benning).
8.22.5.1.3. All outpatients require a five-day supply.
8.22.5.2. CONUS to CONUS. The majority of CONUS to CONUS moves are
completed in an 8-12 hour time frame; therefore a 1-day supply of medication is
adequate.
8.22.5.3. CONUS to OCONUS. Inpatients follow paragraph 8.22.5.1, and outpatients
follow paragraph 8.22.5.1.3 Variations to this policy regarding amount and type of
medication to be sent with outpatients are authorized only if transportation is arranged
using an alternate mode of travel such as commercial air, rail or ground movement based
on anticipated length of travel. In accordance with DoDI 6000.11, documentation in
TRAC2ES for all PM greater than 100 miles is mandatory, regardless of conveyance.
8.22.6. Administration of medication.
8.22.6.1. General information. Administer medications in-flight on the same schedule as
in the originating MTF, or as near as possible. The goal of administering any type of
medication or treatment in the AE system is to maintain the continuity of care from the
originating MTF to the destination MTF without significant delays.
8.22.6.2. Prior to departing the ERPS or MTF, the patient will be assessed for pain and
given pain medications needed within 1 hour of departure. (T-0). If required, administer
152 DAFI48-107V1 15 DECEMBER 2020
other medications within 1 hour of departure. Consider adjusting dosing schedule for
diuretics to ensure patient restroom access.
8.22.6.3. Administration of medication according to established protocols. In emergency
situations, the AECM initiates care based on individual competency, level of knowledge,
AFSC scope of practice and skill. Reference the Nursing Drug Handbook in the in-flight
kit and AHA or equivalent; TNCC if available; DHA/J7 Education and Training
guidelines.
8.22.6.4. 4N0s/X4N0s trained in accordance with the AFMS medication administration
program are allowed to administer medications in accordance with the most current work
center authorized drug list. The AE authorized drug list is the allowance standard.
Applicable areas of CFETP are signed off, to include routes of administration and
schedule of medications commensurate with skill level.
8.22.6.5. Controlled medications.
8.22.6.5.1. A controlled drug accepted by the healthcare provider becomes his/her
responsibility for accountability, control, safeguarding, and disposition. Nurses are
responsible for daily/mission accountability of patient narcotics on each applicable
AF Form 3899 or EHR equivalent. Annotate drug and number available on the EHR
or AF Form 3899 during patient hand-off. WARNING: USAF enlisted ground
personnel may only take control of Schedule II through V medications after they have
been trained and certified by someone appointed by the MTF or equivalent
commander in accordance with the CFETP.
8.22.6.5.2. If positive control of the medication kit has NOT been maintained or if
controlled medication is stored at remote location other than a pharmacy (e.g., a
nurse’s station) or if lock-out tag is compromised, a nurse and another qualified
person will count them at change of shift or the beginning/end of every mission and
when accessed for patient use and document on AF Form 579, Controlled Substances
Register, or in automated equipment logs (e.g., Pyxis ® log), as appropriate. (T-1).
This form is included in the narcotics box for all controlled medications.
8.22.6.5.3. When controlled medications are brought onboard the aircraft, the AECM
and MTF representative together completes an inventory.
8.22.6.5.3.1. The name and quantity of medications are noted and signed for on
the AF Form 3899A, (Front).
8.22.6.5.3.2. If these medications are returned to the MTF, the representative and
AECM annotates in the EHR or AF Form 3899 the statement “Refused and
Returned,” and both persons sign the form.
8.22.6.5.4. During RONs, controlled medications are always secured and are the
responsibility of the FNs when a DoD MTF is not located at the RON site.
8.22.6.5.5. All controlled medications, not in the IFK, accompanies the patient to the
destination MTF.
8.22.6.5.6. Upon termination of the mission, all unaccompanied/unserviceable
controlled medications are documented on the AF Form 3859, Turn-In of
Unaccompanied Narcotics, and turned into the medication room for disposition per
DAFI48-107V1 15 DECEMBER 2020 153
local policy and annotated on the AF Form 3829. Note: If controlled medications are
off loaded at the incorrect MTF, notify C2 for immediate tracking.
8.22.6.5.7. Controlled medications missing/unaccounted for during mission
execution.
8.22.6.5.7.1. As soon as the AECM identifies controlled medications are missing,
report the loss immediately to the PIC.
8.22.6.5.7.2. As soon as possible, the AECM creates a memorandum for record
or affidavit documenting the circumstances surrounding the loss, type, and
quantities of medications missing. If possible, obtain written statements or
affidavits from any persons having knowledge of the circumstances surrounding
the loss. This is submitted to the Chief Nurse for review.
8.22.6.5.7.3. Contact C2 as soon as possible and prior to landing at the next en
route stop or final destination.
8.22.6.5.7.4. C2, in consultation with the governing PMRC, notifies the Office of
Special Investigations or the security police to ensure appropriate steps are taken
upon landing.
8.22.6.5.7.5. If the medications are still not located, the investigating agency
dictates follow on actions. A JPSR worksheet or DD Form 2852 is also be
completed.
8.22.6.5.7.6. Medical personnel assigned as an AECM or to an ERCC UTC may
hand-carry controlled medications when necessary. The member holds orders
stating “may transport controlled medications” and if traveling via commercial
air, has a letter, signed by the commander, stating they are authorized to be a
courier for controlled medications. A copy of the letter signed by the commander
is placed inside of the controlled medication container.
8.22.7. Anaphylaxis. Reference AE Clinical Protocol – Anaphylactic Reaction.
8.22.7.1. Anaphylaxis is a severe, systemic, allergic reaction involving the respiratory
and/or cardiovascular system. It is an immediate, life-threatening reaction caused by
injection, ingestion, inhalation, insect stings or bites. It usually occurs within 30 minutes
of exposure but may take up to two hours to develop.
8.22.7.2. Signs and symptoms may occur within minutes of exposure to allergen and
may include flushing of the skin, itching, hives, edema (primarily of face, tongue,
laryngeal), bronchospasm, cough, wheezing, stridorous breathing, retractions,
hypotension, tachycardia, arrhythmia, palpitations, pallor, dizziness, syncope, anxiety,
lethargy, sudden loss of consciousness, seizures, and coma.
medication; VS, if indicated; known allergies; for women of childbearing years, date of
last menstrual cycle; date and time of administration, notification of a physician, and the
outcome. The following statement is documented on AF Form 3899 “(Insert name of
drug) was administered in accordance with AE Clinical Protocol – Anaphylactic
Reaction. Complete and submit DD Form 2852 or JPSR worksheet.
154 DAFI48-107V1 15 DECEMBER 2020
8.22.8. Documentation.
8.22.8.1. All inpatients will have an up-to-date MAR to ensure accurate and timely
medication administration is conveyed and documented throughout the continuum of
care. (T-0).
8.22.8.2. Every effort is made to ensure the MAR, as well as the electronic forms in the
TRAC2ES, are in agreement.
8.22.8.3. The sending MTF or staging facility is responsible for ensuring the MAR is
completed and sent with the patient.
8.22.8.4. En route MAR documentation is completed at the MTF, ERPS, and in-flight.
Any changes are updated on the MAR and annotated in TRAC2ES by the clinician
initiating the change utilizing the electronic AF Form 3899A within TRAC2ES. If
changes occur in-flight or at an en route staging or RON facility, the PMCC is notified to
update the AF Form 3899A in TRAC2ES.
8.22.9. OTC medication administration.
8.22.9.1. This AFI provides the AECM with the ability to administer OTC medication to
patients, without notifying a physician in advance. The medication is documented on the
EHR or AF Form 3899. In emergency situations, the AECM initiates care based on
individual competency, level of knowledge and skill. Reference the current edition of the
Nursing Drug Handbook or Physicians’ Desk Reference. Medications may be
administered one time, unless otherwise stated, by a trained and competent AECM. If
treatment is not effective contact the VFS and C2 for further physician orders (reference
AE Clinical Protocol – Over-the-Counter Medications Administration).
medication; VS, known allergies, for women of childbearing years: date of last menstrual
cycle, assessment, complaint, pain control management, pertinent past
treatment/medication, date and time of administration and notification of a physician, and
the outcome. The following statement is documented on the EHR or AF Form 3899
“(Insert name of drug) was administered in accordance with AE Clinical Protocol - Over
the Counter Medication Administration”.
8.22.9.2.1. In the EHR or AF Form 3899. Document all medication administration
times in ZULU.
8.22.9.2.2. If patient arrives without an AF Form 3899, but instead with a NATO,
DD Form or service specific medical document, then the information from those
documents are transcribed onto EHR or AF Form 3899, the original documentation is
attached to the EHR or AF Form 3899, and becomes a permanent part of the patient’s
medical record.
8.22.10. High alert medications.
8.22.10.1. High alert medications have a heightened risk of causing patient harm if they
are used in error. The Institute for Safe Medication Practices provides a listing of high
alert medications. The more common high alert medication in the AE system includes
(but not limited to): IV narcotics/opiates, IV anticoagulants, total parenteral nutrition,
and all epidurals and PNBs.
DAFI48-107V1 15 DECEMBER 2020 155
8.22.10.2. Conduct and document independent double-checks with all high-alert IV

medications, all PCA’s, epidurals, and PNBs. Documentation of double-checks is
reflected by two signatures on required forms/flow sheets. This is applicable to ERPS,
ERCC team and AECMs. Note: Documenting “Checked with (other clinicians)” in an
EHR current field is adequate.
8.22.10.2.1. An independent double-check is defined as two authorized medical
persons familiar with the process/equipment/medication (at least one being a RN),
independently verifying the practitioner’s/provider’s orders, medication infusing, and
the correct set up of PCA, PNB, Epidural or IV pump in use (rate, dose, volume to
infuse, medication concentration, basal rate, bolus lockout, etc.).
8.22.10.2.2. Double-checks are conducted and documented when initiating high alert
medications, during hand-offs of care, following a change in orders, and when a new
bag is started.
8.22.11. Unconscious/Difficult to Arouse Patients.
8.22.11.1. Various factors may lead to an unconscious/difficult to arouse patient in the
AE environment. Opiate/narcotic or sedating medication overdose produce inadequate
ventilation/respiration and an altered mental status. For unconscious/difficult to arouse
patients, due to a suspected narcotic or benzodiazepine overdose (reference AE Clinical
Protocol - Narcotic or Benzodiazepine). Otherwise, provide BLS and immediately
contact C2/VFS.
8.22.11.2. For all unconscious/known or suspected narcotic overdose notify the VFS and
C2 for guidance, treatment options and possible diversion.
8.22.11.3. Signs and symptoms of a narcotic overdose.
8.22.11.4. Mental status changes.
8.22.11.5. Hypotension/hypertension.
8.22.11.6. Decreased or absent respiratory rate or tachycardia.
8.22.11.7. Pinpoint pupils, and seizures. Normal pupil examination does NOT exclude
opioid intoxication. Users of meperidine and propoxyphene may present with normal
pupils. The presence of coingestants (such as sympathomimetic or anticholinergics) may
make pupils appear normal or large.
8.22.11.8. If on a PCA (regional or epidural pump) and patient suddenly becomes
difficult to arouse; turn pump off and continue BLS management.
8.22.11.9. Do not rely on patient history of ingestion, especially in patients with
psychiatric history.
8.22.11.10. Make sure patient is not still carrying other medications or has any weapons.
8.22.11.11. Symptoms of opioid withdrawal can include nausea/vomiting, hyperactivity,
increased pain, and combativeness.
medication; VS, if indicated, known allergies; for women of childbearing years: date of
last menstrual cycle, date and time of administration and notification of a physician, and
156 DAFI48-107V1 15 DECEMBER 2020
the outcome. The following statement is documented on AF Form 3899 or EHR

equivalent “(Insert name of drug) was administered in accordance with AE Clinical
Protocol - Narcotic or Benzodiazepine Overdose.” Complete and submit DD Form 2852
or JPSR worksheet.
8.23. IV Therapy.
8.23.1.1. Barometric pressure changes: Air expansion at altitude may cause IV rates to
fluctuate.
8.23.1.2. Situations potentially dangerous to a patient are a sudden surge of fluid,
unregulated flow to the patient, and air bubbles in the administration tubing.
8.23.1.3. Critical area of consideration: Accurate administration of IV therapy poses one
of the greatest concerns in-flight. If the IV is not regulated by the use of an IV infusion
pump, drip rates are reevaluated once cruise altitude is reached, frequently throughout the
flight, after descent, and after a rapid decompression.
8.23.2. IV containers.
8.23.2.1. Plastic IV containers: Plastic solution containers are preferred for in-flight use
because they are easy to handle and secure, do not break, and expand/contract with
changes in barometric pressure without venting.
8.23.2.2. Glass IV containers: IV glass bottles without integral venting rods do not allow
for the escape of expanding air. The expansion of air forces the fluid out of the bottle or
the IV does not flow. Note: Do not use glass bottles without venting them.
8.23.2.3. Venting procedures: Any rigid plastic or glass IV bottle requires venting.
8.23.2.3.1. Insert an 18-gauge needle through the bottle cap into the lumen of the
integral air rod of the bottle.
8.23.2.3.2. Remove the cap from the air vent on the drip set and insert a sterile 3 ml
syringe into the vent.
8.23.2.3.3. Secure the syringe and plunger into the vent by running a strip of tape
over the plunger of the syringe and around the neck of the IV bottle. As the air of the
bottle expands it leaves via the needle inserted into the air rod; the syringe acts as a
plug, held in place by the tape, and prevents fluid from pouring out of the bottle.
8.23.2.3.4. Non-vented drip sets: When non-vented drip sets are used, it is necessary
to insert a needle only into the integral air rod of the IV bottle.
8.23.2.3.5. Volutrol (metered drip sets constructed of pliable plastic): The meter
chamber is filled and clamped off between the bottle and the chamber. Since the
meter chamber collapses as it empties, air does not enter or expand in the chamber.
8.23.2.3.6. Metered drip sets constructed of rigid plastic: Systems with air vents in
the metering section of the drip set allow air in the tubing during rapid decompression
and are not used.
8.23.3. IV therapy: Preflight/in-flight considerations.
DAFI48-107V1 15 DECEMBER 2020 157
8.23.3.1. Document the IV start time, site, catheter gauge, and the last dressing change, if
known.
8.23.3.2. Label IV bag with solution, date, start and stop times and initials. Do not use
markers because they are absorbed into the plastic bag.
8.23.3.3. Infusion pumps are used for heparin, cardiac and vasoactive medications,
neonatal/ pediatric patients, and total parenteral nutrition (reference AE Medical
Equipment Compendium).
8.23.3.4. Ensure the line is patent.
8.23.3.5. Assess insertion site and evaluate for infection/irritation: Redness/red streaks
at insertion site, warmth, edema, purulence/drainage, and pain.
8.23.3.6. Ensure patient has enough IVs, medications, and supplies to reach the
destination facility.
8.23.3.6.1. When patient medical supplies and PMI are coordinated with the AE
system in advance, most items are provided from the AE staging base.
8.23.3.6.2. Without advance coordination, the originating facility is responsible for
providing these items and for providing a one-day minimum of supplies, except for
patient movement from theater to CONUS and within CONUS where a three-day
minimum is provided.
8.23.3.7. Place patients receiving IV therapy to facilitate IV flow, if possible (if the IV is
not managed with an IV infusion pump).
8.23.3.8. After a rapid decompression, the following difficulties may be encountered:
Bags/bottles break, drip sets pop out, blood backs up into tubing, and excessive air and
fluid is forced into patient.
8.23.3.9. AECM actions following a rapid decompression: Clamp tubing, check infusion
site, bottle or bag, infusion pump (if applicable), and tubing. Assess for signs and
symptoms of infiltration. Clear the tubing of air and resume infusion if not clotted or
infiltrated.
8.24. Management/Administration of Blood and Blood Products.
8.24.1. All blood products carried in the AE system are transported as rapidly as possible at
the appropriate temperature, in standard blood shipping boxes consisting of an outer
cardboard box with a Styrofoam insert. Blood temperature during transport needs to be
maintained between 1-10 degrees C for liquid RBCs. Fresh frozen plasma and frozen
cryoprecipitate is maintained in the frozen state (it is usually shipped in dry ice). Note: AE
usually does not transport blood shipments which is handled through class VIII B channels.
8.24.2. Blood shipping containers are not be exposed to extreme temperatures (below 1
degree C or over 27 degrees C). All blood components remain securely packed in the
approved container for the duration of the flight or administered. The container is always
secured during transport.
8.24.2.1. Either DD Form 1502, Frozen Medical Materiel Shipment, or DD Form 1502-
1, Chilled Medical Materiel Shipment, is posted on the front of all blood shipping boxes.
158 DAFI48-107V1 15 DECEMBER 2020
8.24.2.2. All blood products are packed in accordance with sending facility protocols.
8.24.2.3. Re-icing is the responsibility of the originating and RON MTF. If there is an en
route delay of more than 48 hours, the AECM, or the carrier agent, contacts the special
handling department on the flight line for guidance and assures the re-icing of the blood
products. The re-icing is annotated on DD Form 1502 or DD Form 1502-1. The PMRC is
informed of any blood product transfer so arrangements are made with an en route
MTF(s) for re-icing. WARNING: Do not use dry ice, salted wet ice, water frozen in
polyurethane bags, super cooled canned ice, and commercial “blue ice” containers for re-
icing liquid blood product shipments.
8.24.3. AECMs/Specialty team only accept blood components that are:
8.24.3.1. To be administered during the AE mission.
8.24.3.2. In an approved blood shipment container, which can be opened briefly and
checked for the correct amount and components according to the written order. Note:
The blood products check includes comparison of the blood products with three
identifiers for the patient (full name, DOB, Social Security Number [SSN]) and the
written order.
8.24.3.3. With adequate ice. Do not accept a container of blood with little or no visible
ice.
8.24.3.4. All discrepancies are brought to the immediate attention of the person(s)
shipping the container. If the discrepancies are not resolved, the AECM may refuse to
transport the blood products. Notify the PMRC.
8.24.4. Blood and blood product administration guidelines.
8.24.4.1. A provider writes the order for administration of blood or blood components.
8.24.4.2. Use standard precautions when handling blood and blood products.
8.24.4.3. Pre-administration of blood products includes: Current patient consent for
transfusion, documentation of patient understanding of blood transfusion reason, and
potential side effects.
8.24.4.4. Verify patient identification with another clinician by patient stating full name,
DOB, SSN. This information is checked against the wrist band.
8.24.4.5. Verify patient identification and blood product label. Compare the name, date
of birth, and SSN number on the wristband with the bag tag. Compare blood group and
rhesus factor compatibility by comparing the bag label, bag tag, medical record, and
transfusion form. Note: Check bag label for expiration date and satisfactory serologic
testing.
8.24.4.6. Document on transfusion record names of persons starting the infusion and
stopping infusions.
8.24.4.7. Utilize blood transfusion tubing and filter as prescribed. Prior to initiation of
blood product take a full set of VS to include temperature. No medications or solutions
are added to or transfused concurrently with blood components except NS.
8.24.4.8. The total volume infused is documented on available I&O record.
DAFI48-107V1 15 DECEMBER 2020 159
8.24.4.9. Start infusion slowly (e.g., 2 ml/minute). Note the time from the time the blood
begins infusing at the IV port site. Remain with the patient for fifteen minutes and assess
for transfusion reaction in accordance with paragraph 8.24.5
8.24.4.10. Reassess patient for signs and symptoms of transfusion reaction (e.g., acute
hemolytic, anaphylactic) at least hourly. Note: Transfusion reactions usually occur
within the first 50-100 ml.
8.24.4.11. Acute reactions can occur at any time during the transfusions.
8.24.4.12. Documentation of assessment is required. Note: For all blood component
infusions, it is imperative that the patient be closely monitored for acute reactions.
8.24.4.13. Whole blood, RBC, and fresh frozen plasma (FFP) is hung within thirty
minutes of removal from the blood-shipping container.
8.24.4.14. Whole blood and RBCs is transfused within 4 hours and at the prescribed rate.
8.24.4.15. FFP infused at the rate prescribed. The infusion may be completed within 15
to 30 minutes depending on total volume.
8.24.4.16. Cryoprecipitate, once thawed, is infused immediately. Run over 3 - 15
minutes.
8.24.4.17. Platelets may be transported at room temperature between 20-24o C or 68 -
75.2o F. The transfusion may be completed within 20-60 minutes depending on total
volume.
8.24.4.18. Blood and blood components may be administered during emergent
contingency and wartime ground and in-flight operations, and consent for transfusion is
implied.
8.24.5. Blood transfusion reactions. Unexpected complications can occur in any blood
transfusion recipient. These adverse reactions can be categorized as immunologic, infectious,
chemical, and physical, and some are further subdivided into acute and delayed reactions.
The most clinically important adverse effects of transfusion are infectious or immunological
occurrences. Stringent screening requirements have drastically reduced the risk of transfusion
acquired pathogens such as Hepatitis B, HIV and Hepatitis C thereby resulting in a marked
reduction in infectious related reactions. Additionally, infectious complications and delayed
hemolytic transfusion reactions generally manifest themselves 3-7 days post transfusion and
therefore are outside of the scope of the AECP.
8.24.5.1. The classic transfusion reactions are immunologic in nature. Acute reactions
occur in 1% to 2% of transfused patients. Severe transfusion reactions are most likely to
occur during the first 15 minutes of infusion. Therefore, to facilitate early recognition of
potentially life-threatening complications, patients are monitored closely upon initiation
of any blood transfusion product. Examples of classic immunologic transfusion reactions
include febrile non-hemolytic transfusion reactions (FNHTR); acute hemolytic
transfusion reaction (AHTR) and allergic reactions (urticarial and anaphylactic allergic
reactions) (reference AE Clinical Protocol - Reaction to Blood Products).
8.24.5.2. For all known or suspected blood transfusion reactions notify the VFS and C2
for guidance and possible diversion to a MTF capable of handling the situation.
160 DAFI48-107V1 15 DECEMBER 2020
8.24.5.3. Documentation of any blood product reaction includes subjective and objective
data for giving medication; VS, known allergies, women of childbearing years, date of
last menstrual cycle; date and time of administration and notification of a physician, and
the outcome. The following statement is documented on the EHR or AF Form 3899
“(Insert name of drug) was administered in accordance with AE Clinical Protocol -
Reaction to Blood Products.” Complete DD Form 2852 or JPSR worksheet.
8.25. Infection Control.
8.25.1. Infection control can be difficult in the dynamic physical environment of AE.
Therefore, originating physicians are vigilant of the presence of communicable diseases that
could spread to other patients, the crew, or the destination MTF community.
8.25.2. General principles of infection control.
8.25.2.1. The guidelines for personnel and recommended standards of patient care are
contained in the most current Centers for Disease Control and Prevention (CDC)
guidelines and in local cleaning directives.
8.25.2.2. All medical personnel in the AE environment implements Standard Precautions
with all patients coupled with Transmission Based Precautions as required. AFMAN 44-
156, Treatment of Biological Warfare Agent Casualties, is available for additional
guidance.
8.25.2.3. Brief all infectious patients and their attendants on isolation procedures and
precautions.
8.25.2.4. Each aircraft and mission is unique. Environmental lighting in most cases is
poor, making the visualization of blood and body fluids highly uncertain. The practice of
infection control within the AE setting adheres to the following principles:
8.25.2.4.1. The aircraft is considered a dirty environment. Normally dressings are
reinforced unless there is evidence of significant blood loss.
8.25.2.4.2. Medical personnel with “actively” exudative lesions or weeping
dermatitis are not scheduled for missions until resolved/cleared by a flight surgeon. If
excess drainage occurs during flight, bandage the wound area and limit patient
contact until seen by a flight surgeon.
8.25.2.4.3. Fingernails comply with AFI 44-108, Infection Prevention and Control
Program.
8.25.2.4.4. NOMEX/leather gloves are not worn while administering patient care.
8.25.2.4.5. Eating, drinking, applying cosmetics, and handling contact lenses is
prohibited in work areas where there is a likelihood of exposure to blood and body
fluids (BBF).
8.25.2.4.6. Food and drinks are prohibited on countertops where blood and other
potentially infected material are stored or placed. Exception: On cargo aircraft this
may not be feasible. Ensure the loadmaster/boom operator is notified of the
storage/placement of such items, in order that they may disseminate the information
to the rest of the crew.
DAFI48-107V1 15 DECEMBER 2020 161
8.25.2.5. Patient assignment and placement of patients. Note: The airflow of each
aircraft governs litter and seat assignments for high risk immune compromised patients or
patients on airborne or droplet precautions (reference Attachment 14).
8.25.2.5.1. High-risk patients (e.g., those particularly susceptible to infection:
leukemia, cancer and post-op patients) are located as far as possible from infectious
patients. All efforts are made to limit the number of care givers to either highly
infectious or neutrophilic patient populations. Consider the direction of airflow in the
aircraft and having the high-risk patient wear the N-95 mask en route.
8.25.2.5.2. Known or suspected infectious patients not requiring airborne precautions
are placed in the lowest litter position.
8.25.2.5.3. When feasible, assign a single caregiver to infectious patients or to those
who are at high risk for infection. Avoid mixing infectious patients and those at high
risk for infection, whenever possible.
8.25.2.5.4. Patients with known or suspected wound infections are not placed in the
same area as patients with clean wounds.
8.25.2.5.5. Infectious ambulatory patients are seated away from other patients if
possible.
8.25.2.5.6. In the event there are patients who have active infections with the same
disease (e.g., TB, measles, tularemia, cholera), they may be moved as groups or
cohorted in another area of the aircraft that meets safe ventilation and airflow
requirements for Airborne Precautions.
8.25.2.5.7. In austere ground operation settings with limited airflow (e.g., AMBUS,
Humvee, tentage), the infectious patient wears a surgical mask or N95 mask. The
patient is placed downwind, to the greatest extent possible, near the airflow exit and
away from other patients. Note: When in confined areas and/or in areas with poor air
circulation, both the patient and the health care worker (HCW) wear a N95 mask.
8.25.3. Standard precautions.
8.25.3.1. Handwashing.
8.25.3.1.1. Handwashing is the single most important method for preventing the
spread of infection.
8.25.3.1.2. Handwashing is accomplished with soap and running water, when
available.
8.25.3.1.3. AE approved waterless hand cleaners/antiseptics may be used as an
adjunct to routine hand washing or when hand washing facilities are inadequate,
inaccessible, or when there is an interruption in the water supply. Waterless hand
antiseptics may come in a foam, gel, or towelette. Note: If visible soiling is present
on the hands, a towelette offers the physical removal of the dirt and is the first choice
for hand antisepsis. Follow manufacturer’s directions for use. Note: Waterless hand
cleaners/antiseptics are not effective against all organisms (e.g., C. Difficile).
8.25.3.1.4. Wash hands or use hand antiseptic before and after each patient contact;
immediately after removing gloves or other personal protective attire (e.g., gowns,
162 DAFI48-107V1 15 DECEMBER 2020
masks, goggles); before dispensing medications, performing invasive procedures,

touching wounds or touching patients who are susceptible to infection; before serving
meals; and after sneezing, coughing, eating, and performing personal hygiene.
8.25.3.2. Personal protective equipment (PPE). Worn appropriate for the task, whenever
exposure to BBF is anticipated.
8.25.3.2.1. Gloves.
8.25.3.2.1.1. Use disposable, single-use gloves.
8.25.3.2.1.2. Change gloves after contact with contaminated materials, even if
care of that patient is not complete. Remove gloves using glove in glove
technique.
8.25.3.2.1.3. Change gloves between each patient.
8.25.3.2.1.4. Wear gloves while serving/handling patient’s food.
8.25.3.2.1.5. Remove gloves promptly after use and before touching non-
contaminated items/surfaces.
8.25.3.2.1.6. Wash hands immediately after removing gloves.
8.25.3.2.2. Gowns.
8.25.3.2.2.1. Fluid-repellent gowns are worn to protect skin and prevent soiling
of clothing during procedures and patient care activities likely to generate
splashes or sprays of BBF. In the event the HCW clothing is contaminated with
BBF, a gown may be worn for a short duration to prevent cross contamination.
8.25.3.2.2.2. Promptly discard BBF contaminated disposable gowns after use in
designated biohazard trash bags.
8.25.3.2.3. Goggles and masks.
8.25.3.2.3.1. Goggles, safety glasses with side shields or mask with a visor are
worn anytime splashing of BBF is anticipated. Normal eyeglasses are not
considered protective apparel. When worn for PPE, masks and goggles protect the
wearer from splashes or sprays of BBF.
8.25.3.2.3.2. Fluid resistant surgical masks are appropriate and are changed when
moist; or change after two hours of wear or when wet.
8.25.3.2.3.3. The N95 respirator is approved for in-flight wear and is worn by all
caregivers when providing immediate care to a patient with a suspected or actual
airborne transmissible infection. Additionally, the patient for whom the disease is
suspected wears the N95 (without an exhalation valve) or surgical mask.
8.25.3.2.3.3.1. The N95 mask is fit tested for all AECMs by a local
Bioenvironmental Engineer or a certified fit-tester in accordance with AFI 48-
137, Respiratory Protection Program, and local policy prior to wear by
medical personnel.
8.25.3.2.3.3.2. All personnel and patients changes the mask whenever wet or
contaminated with BBF, if the straps are loose or if the mask is damaged, and
DAFI48-107V1 15 DECEMBER 2020 163
by personnel after completing direct patient care. Note: The N95 mask cannot
be reused once it is removed.
8.25.3.2.3.4. Use a resuscitation mask or bag-valve mask to avoid mouth-to-
mouth contact.
8.25.3.3. Needles and syringes/sharps.
8.25.3.3.1. Do not recap used needles. Note: Recapping is acceptable if blood is
drawn and no blood tubes are available, use a one-handed scoop technique. Secure
the cap with tape.
8.25.3.3.2. Do not bend or break needles.
8.25.3.3.3. Place needles in a puncture resistant container maintained as close to the
point of use as possible.
8.25.3.3.4. After securing the sharps container in the closed position, off load sharps
container according to local policy.
8.25.3.4. Biohazardous waste.
8.25.3.4.1. Biohazardous waste is defined as liquid or semi-liquid blood or other
potentially infectious materials, contaminated items that would release blood, or other
potentially infectious materials, in a liquid or semi-liquid state if compressed. Items
that are caked with dried blood or other potentially infectious materials and can
release these materials during handling; contaminated sharps (Ref paragraph
8.25.3.3) or pathological and microbiological wastes containing blood or other
potentially infectious materials.
8.25.3.4.2. Place a red biohazard bag at the end of the patient’s litter, if BBF is
expected. Biohazard bags are not used for trash not contaminated with BBF waste.
8.25.3.4.3. Double-bag waste if there is a potential for leakage.
8.25.3.4.4. Off-load with the patient for disposal at the local MTF.
8.25.3.5. Linen.
8.25.3.5.1. All used linen is handled as if potentially infectious.
8.25.3.5.2. Handle used linen as little as possible, with a minimum agitation, to
prevent the potential dissemination of microorganisms.
8.25.3.5.3. Place soiled linen in a clear plastic bag to offload with the patient unless
contaminated with BBF. Linen contaminated with BBF is placed in a red bag.
8.25.3.6. Urine and feces.
8.25.3.6.1. Urine and feces from all patients, including those on isolation
precautions, can be flushed down the aircraft toilet.
8.25.3.6.2. Disposable urinals are used as needed and discarded in the proper waste
bag.
8.25.3.6.3. The equipment table of allowances for bedpans is limited. If unavoidable,
use of bedpans for several patients is accomplished by lining bedpans with a plastic
164 DAFI48-107V1 15 DECEMBER 2020
bag and taping securely to prevent slippage and spillage. For truly immobile patients,
the patient stage or MTF provides a bedpan per patient.
8.25.3.6.4. Dispose of waste in aircraft toilet, then carefully remove bag, keeping the
soiled portion of the bag to the inside, roll/gather bag closed and dispose in the proper
waste bag.
8.25.3.6.5. Separate toileting is preferred when patients require second tier isolation
precautions for known or suspected pathogenic microorganisms, communicable
diseases, or colonized pathogenic microorganisms. When separate toileting is not
practical, AECMs disinfect the latrine after patient use with approved disinfectant
wipes/solution.
8.25.3.7. Cleaning/disinfecting. Note: Performed by AECMs.
8.25.3.7.1. Routine cleaning in accordance with CDC guidelines/recommendations of
contaminated areas of the cabin that come in direct contact with patients helps
prevent the spread of microorganisms.
8.25.3.7.2. PPE is worn appropriate for the task minimally, gloves are worn.
8.25.3.7.3. Use AE approved detergent/disinfectant to clean and disinfect patient care
areas in accordance with CDC guidelines/recommendations.
8.25.3.7.4. Clean/disinfect surfaces using a damp cloth/disposable washcloth or AE
approve pre-package kits; allow to air dry.
8.25.3.7.5. Areas used for medication and food preparation areas are
cleaned/disinfected prior to use.
8.25.3.7.6. BBF spill cleanup.
8.25.3.7.6.1. Place an absorbent material over spill.
8.25.3.7.6.2. Blot up and dispose of in a red biohazard bag.
8.25.3.7.6.3. Pour/spray/clean area with AE approved disinfectant/detergent.
8.25.3.7.6.4. Allow to air dry.
8.25.3.7.7. BBF contamination of seats/cushions.
8.25.3.7.7.1. Coordinate with loadmaster/crew chief in accordance with local
policy.
8.25.3.7.7.2. Remove web seat/seat cushion and seat back and place in a red
biohazard bag.
8.25.3.7.7.3. Label with suspected/known BBF source.
8.25.3.7.8. Offloading patients.
8.25.3.7.8.1. Send all used disposable patient care items with the patient, or as
directed by AMC/SG.
8.25.3.7.8.2. There is no need to “decontaminate” the interior of the aircraft for
routine transport of patients. If using transmission-based precautions, clean
surfaces the patient had immediate contact with by wiping area off using a cloth
DAFI48-107V1 15 DECEMBER 2020 165
containing the approved detergent/disinfectant. Seat cushions and litters may need
cleaning depending on the level of contamination.
8.25.3.7.9. Contaminated reusable patient care equipment.
8.25.3.7.9.1. Place in biohazard bag and label with type of contaminants.
8.25.3.7.9.2. AE equipment dedicated to patients follows the patient to final
destination. AE allowance standard PMI equipment remains with the AE crew
and is decontaminated in accordance with squadron policy.
8.25.3.7.9.3. If mission RONs, remove equipment and transfer to the staging
facility or supporting MTF for decontamination or in accordance with local
policy.
8.25.3.7.9.4. Decontaminate equipment prior to servicing or shipping. When this
is not feasible, equipment is placed in a labeled universal biohazard bag with a
listing of the contaminated portions of equipment.
8.25.3.7.9.5. In the staging facility, cleaning is accomplished using a
germicidal/fungicidal liquid solution in accordance with local policy.
8.25.3.7.10. Aircraft decontamination. Not an AECM duty. In the event of suspected
or known contamination, the PIC and the AECM notifies C2 who then contacts the
governing PMRC and the VFS for further guidance.
8.25.3.7.11. Disinfect latrines after patient use as described in paragraph 8.25.3.6.5
8.25.3.8. Irrigation fluids, multi-dose vials, and sterile supplies.
8.25.3.8.1. Irrigation fluids – If used on an AE mission, discard at the end of the
mission. If used in the ERPS, label with date and time and use for only 24 hours;
discard remainder after 24 hours.
8.25.3.8.2. Multi-dose vials – If a multi-dose has been opened or accessed (e.g.,
needle-punctured), the vial is dated and discarded within 28 days unless the
manufacturer specifies a different (shorter or longer) date. If a multi-dose vial has not
been opened or accessed (e.g., needle-punctured), it is discarded according to the
manufacturer’s expiration date. Open and follow manufacturer’s suggestion for
disposal. Note: Some vials may appear to be multi-dose when in fact, they are single
dose (e.g., NS). Note: Dispose of vials whenever sterility is compromised or
questionable or if there is any sign of or known contamination, color change, or
foreign particles found.
8.25.3.8.3. Sterile supplies - check prior to flight for expiration dates, tears, evidence
of liquid spills, and/or color change.
8.25.3.8.3.1. Expired disposable items are not reprocessed.
8.25.3.8.3.2. Shelf-life sterility is either event-related and/or time-related:
8.25.3.8.3.3. Event-related sterility means as long as an “event” has not occurred
to compromise sterility, the item is considered sterile. An event may include any
of the following: the package is torn, ripped open, compromised in a way that
causes the healthcare worker to question the integrity of the contents.
166 DAFI48-107V1 15 DECEMBER 2020
8.25.3.8.3.4. Date-related sterility is based on the type of packaging and has a tag
with an expiration date.
8.25.3.8.4. Disposable items are not reused or reprocessed.
8.25.4. The following patient movements will be specifically coordinated by the PMRC and
USTRANSCOM/SG and will follow USTRANSCOM Instruction 41-02; Patient Movement
of Contaminated, Contagious or Potentially Exposed Casualties: Multi-drug resistant
Mycobacterium Tuberculosis (MDR-TB), Congo Crimean Hemorrhagic Fever (CCHF),
plague, smallpox, cholera, yellow fever, typhus, Ebola, malaria, polio, influenza, and any
other diseases under special surveillance by the CDC. (T-0).
8.25.5. Transmission based isolation precautions. There are two tiers to isolation. The first is
the use of Standard Precautions with every patient contact. The second tier is the
transmissions-based precautions for isolating known or suspected pathogenic
microorganisms, communicable diseases, or colonized pathogenic microorganisms. For
further guidance, AFMAN 11-2AEV3 and AFMAN 44-156.
8.25.6. Airborne precautions. Airborne precautions prevent transmission of infectious
particles aerosolized or suspended in the air. When they are inhaled, they enter the
respiratory tract and can cause infection. Since air currents can disperse these particles over
long distances, airborne transmission does not require face-to-face contact with an infected
individual. Only a limited number of diseases are transmissible via the airborne route.
Airborne isolation cannot be maintained in open aircraft. Use of a biocontainment unit is
strongly recommended to move this type of patient. Reference Transportation Isolation
System (TIS) and Negative Pressure Conex (NPC) CONOPS on the EFB.
8.25.6.1. Patients are segregated to the greatest extent possible. If no biocontainment unit
is available, patient placement is in a low traffic area, downwind and near the aircraft’s
airflow exit, if possible. The aircraft airflow (reference Attachment 14) determines
patient placement. A litter is optional for ambulatory patients and is placed in the lowest
position in the tier. Place ambulatory patients next to the sidewall.
8.25.6.2. Patients requiring airborne precautions are regulated on a designated/dedicated
mission with limited crew and with no other patients or passengers on board.
8.25.6.3. The patient always wears a surgical mask (sent by the sending facility) unless
contraindicated. The mask should not have noticeable gaps. Note: Patients requiring
airborne precautions and O2 may wear a surgical mask over the nasal cannula (1-6 LPM).
Alternatively, an infectious aerosol capture mask or other approved device demonstrated
to contain respiratory aerosols may be used in lieu of a surgical mask. WARNING:
Patients requiring higher levels of O2 are assessed prior to flight for eligibility for
invasive respiratory support (intubation and mechanical ventilation) and may require a
cabin altitude restriction or a non-rebreather (NRB) O2 mask. NRB O2 mask does not
have High Efficiency Particulate Air (HEPA) filtration. Place patients using NRB O2
masks as close as possible to the aircraft’s air outflow during the flight.
8.25.6.4. VFS receives approval from destination MAJCOM/CC and MAJCOM/SG, and
the USTRANSCOM/CC and TCSG to use these aircraft during AE intertheater
operations. Note: Consider regional medical intelligence reports and threats when
planning AE transport. WARNING: TB, Measles, Varicella, and certain high
DAFI48-107V1 15 DECEMBER 2020 167
consequence infectious diseases (HCID) pose a high risk to both medical and air crews
due to the potential for airborne or aerosolized respiratory particles.
8.25.6.5. All mission crewmembers (e.g., loadmaster, boom operator, pilot) will be fit
tested for the N95 just-in-time for the mission. (T-1). All aircrew will wear an N-95
respirator for the entire mission with the following exceptions: A biocontainment
transport unit or KC-10 aircraft is utilized for the mission. (T-1). HCWs, MAs and
AECMs will wear a Powered Air Purifying respirator (PAPR) or a fit tested N-95
respirator. (T-1). All personnel minimizes doffing respiratory protection. An IV may be
ordered for hydration for patients.
8.25.6.6. On the KC-10, the flight deck crew may not require N-95 respirator wear
during flight if the following conditions are met: smoke curtain remains closed to
separate patient compartment from flight deck, crew board first through separate front
entrance and activate HVAC high flow configuration, forward boarding door is closed
and flight deck crew remain on board until patients deplaned and rear door is closed. All
mission personnel in the patient care area require N-95 respirator or higher level of
respiratory protection.
8.25.6.7. Air crew are trained on appropriate hand hygiene practice to include before and
after eating or drinking, latrine use, or entering/exiting crew compartments.
8.25.6.8. All mission personnel minimizes food and drink exposure to open air (re-
sealable containers, water bottles, camelbacks, etc.).
8.25.6.9. Ventilators have a HEPA filter connected to the air intake and exhalation limb
of the ventilator circuit. Secure ventilation tubing connections and use in-line suctioning.
8.25.6.10. Portable suction devices have a HEPA filter connected to suction exhaust.
8.25.7. Cleaning of patient care area occurs as appropriate for infectious agent.
8.25.8. Airborne precautions: Pre-mission and post-mission requirements.
8.25.8.1. Pre-mission planning: AECM coordinates mission PPE requirements with the
PIC and medical support personnel. This includes sufficient number of N-95 respirators
and PPE to meet mission requirements as well as replacements due to contamination and
damage of the PPE. Planning also includes PPE requirements for aircrew and ground
support personnel servicing the mission.
8.25.8.2. Ensure AECMs have current N-95 fit test (reference AFI 44-108).
8.25.8.3. AECM coordinates via the off-load message N-95 respirator requirements with
mission ground support personnel.
8.25.8.4. At mission termination, the following information is submitted to the PMRC
and the unit infection control or public health officer, mission number/date, total time the
patient was on the aircraft, personnel’s name, rank, unit of assignment and phone
number; mission position, and approximate time in direct patient care.
8.25.8.4.1. Upon mission termination, all exits and doors are opened and the interior
of the aircraft is aired out. No one enters the aircraft without a N-95 respirator until
the aircraft is aired out (reference Attachment 14 and AFMAN 10-2503, Operations
168 DAFI48-107V1 15 DECEMBER 2020
in a Chemical, Biological, Radiological and Nuclear (CBRN) Environment, aircraft

decontamination section).
8.25.8.4.2. All mission personnel follows-up after mission completion at their local
MTF or in accordance with local policy. If any mission personnel have an infectious
exposure, home station public health office evaluates the need for follow-up testing
and prophylaxis. If not at home station, contact C2 of the mission for instruction.
Results of any required testing is forwarded by home station Flight Surgeons Office
to the PMRC 100 days post mission. The PMRC reviews and forwards personnel
mission data to AMC/SGP.
8.25.8.5. Transport of patients with known TB; including infants and young children are
transported using airborne precautions unless patients have received at least 14 or more
days of appropriate treatment and have clinical improvement. Patients with laryngeal TB
will receive at least 30 days of therapy with appropriate treatment regardless of smear
status. (T-0).
8.25.8.6. Patients with undiagnosed pulmonary infections with suspicion for TB or
patients with HIV going for evaluation of a new undiagnosed pulmonary process are
transported with airborne precautions unless they have negative sputum smears on three
consecutive days or two negative MTb PCR assays (reference Attachment 15).
8.25.9. Droplet Precautions. Use with patients who have infections spread by particle
droplets generally larger than 5µ in size, generated by the infected patient during coughing,
sneezing, talking, or during respiratory-care procedures. This includes microorganisms such
as influenza, pneumonic plague, CCHF, rubella, diphtheria, mumps, pertussis, Neisseria
meningitis, Hemophilus influenza, Mycoplasma pneumonia, Group A streptococcus, and
adenovirus. Droplet precautions are continued throughout the course of illness for viral
respiratory pathogens but may be discontinued after 24 hours of appropriate antibiotics for
bacterial respiratory pathogens.
8.25.9.1. Patients on Droplet precautions are kept a minimum of 6 feet apart.
8.25.9.2. Transmitted through mucosal surfaces (conjunctiva, nasal, and oral mucosa).
8.25.9.3. Instruct the patient on the wear of the surgical mask, the use and disposal of
tissues in the appropriate waste bag, and hand hygiene.
8.25.9.4. All caregivers and AECMs follow Standard, Droplet, and Contact Precautions
(surgical mask, gown, gloves, and eye protection [face shield or goggles]).
8.25.9.5. Follow the guidelines for Airborne Precaution Guidelines regarding patient
positioning on aircraft.
8.25.10. Contact precautions. Use with patients who are infected or colonized by a
microorganism that spreads by direct contact (skin-to-skin) or indirect contact (touch) with a
contaminated object in patient’s environment. (e.g., GI illnesses such as Norovirus and
Clostridioides difficile, respiratory infections such as Respiratory Syncytial Virus or Metap
neumovirus, skin or wound infections such as Methicillin Resistant Staphylococcus aureus,
multi-drug resistant microorganisms such as vancomycin resistant enterococcus and
methicillin resistant staphylococcus aureus, extended spectrum beta lactamase producing
gram negative bacilli, carbapenem resistant enterobacteriaceae, Acinetobacter baumannii,
DAFI48-107V1 15 DECEMBER 2020 169
and infestations such as scabies and pediculosis). Follow Standard Precaution guidelines.
Note: Use gown, and gloves when providing direct patient care.
8.25.10.1. Suspect multi-drug resistant organisms in patients, who sustained a wound
during combat or while deployed, have been hospitalized more than one week, were in a
critical care setting, are recovering from multiple traumas, have indwelling catheters, and
multiple tubes.
8.25.10.2. A clean sheet or chux may be placed over the wound site to prevent
contamination of litter or seat. Treat all linens as contaminated.
8.25.10.3. Suspect C. Difficile if the patient has a history of recent antibiotic use and
loose stools greater than 3 in 24 hours.
8.25.11. Infection control special interest items.
8.25.11.1. Vaccinia patients. Vaccinia virus infections are complications of smallpox
vaccination. This infection should not be confused with smallpox disease, caused by
variola virus. While vaccinia is a contact transmission hazard (e.g., contagious), it is
significantly less infectious and pathogenic than variola (smallpox).
8.25.11.1.1. Vaccinia patients are contact transmission hazards and require
standard/contact transmission-based precautions, including:
8.25.11.1.1.1. Thorough hand washing after patient contact is the most important.
8.25.11.1.1.2. Wear of PPE (gloves and gowns).
8.25.11.1.1.3. Handle of BBF as infectious for blood-borne pathogens.
8.25.11.1.1.4. Terminal cleaning of the patient area.
8.25.11.1.1.5. A clean sheet or chux is placed over the site to prevent
contamination of the litter or seat; treat all linens as contaminated.
8.25.11.1.2. For those directly caring for a vaccinia patient, the following additional
screening criteria completed by the home station flight surgeon's office, may be
considered, but is not mandatory:
8.25.11.1.2.1. No immunosuppression due to medication or underlying medical
condition.
8.25.11.1.2.2. No history of eczema, atopic dermatitis, or active skin disease
(including psoriasis, moderately severe acne, and other forms of dermatitis).
8.25.11.1.2.3. Not pregnant.
8.25.11.1.2.4. No recent photorefractive keratectomy (PRK) or use of ophthalmic
steroid drops.
8.25.11.1.3. Vaccinia wounds are covered, preferably with dry, cotton gauze
dressings, and are reinforced in-flight, as needed. Occlusive dressings are avoided.
Do not change dressings in-flight; reinforce only.
8.25.11.1.4. Requires dedicated PMI.
170 DAFI48-107V1 15 DECEMBER 2020
8.25.11.1.5. Minimize potential for cross-contamination of non-vaccinia patients.

When feasible, assign a single caregiver. If operationally feasible, personnel caring
for vaccinia patients are not assigned to care for patients with the following medical
conditions: Immunosuppression, to include HIV, cancer, burns, sepsis, autoimmune
disorders, trauma, steroid use, skin disease, pregnancy, or recent PRK.
8.25.11.2. Managing suspected highly communicable diseases (reference
USTRANSCOM Instruction 41-02; Patient Movement of Contaminated, Contagious or
Potentially Exposed Casualties).
8.25.11.2.1. Transported on a dedicated mission with the minimum number of crew
members.
8.25.11.2.2. If possible, place a surgical mask on the patient to contain droplets
expelled during coughing unless contraindicated. Instruct patient on cough etiquette,
e.g., to cover the mouth/nose with tissue when coughing or cough into fabric of
sleeve.
8.25.11.2.3. Oxygen delivery with a nasal cannula under a surgical mask, simple face
mask or non-rebreather mask may be used to provide supplemental oxygen support
during transport. In event of respiratory decompensation, positive-pressure ventilation
via BVM is accomplished with a HEPA filter attached to BVM and a secure seal on
patient face. A HEPA filter is placed on exhalation port of the ventilator circuit for
mechanical ventilation.
8.25.12. Healthcare Worker Blood and Body Fluid Post-Exposure Plan.
8.25.12.1. This AFI provides guidance for Post-Exposure Plan (PEP) regimens.
8.25.12.2. The most important strategy for preventing occupationally acquired human
immunodeficiency virus (HIV) infection and other blood-borne pathogens is to
implement Standard Precautions coupled with Transmission-Base Precautions. The risk
of acquiring an infection depends upon the type of injury, the volume of material, and the
patient’s virus titer.
8.25.12.3. Prompt management of occupational exposures and, if indicated, initiation of
PEP as soon as possible after exposure provides the best outcome for personnel exposed.
8.25.12.4. Consultation with the VFS on post-exposure management strategies
(especially determining whether an exposure has occurred and selecting PEP regimens,
particularly when the source patient is antiretroviral treatment-experienced).
8.25.12.5. Testing of source patients (without delaying PEP initiation in the exposed
provider) using methods that produce rapid results once the patient is at their final
destination or first en route stop.
8.25.12.6. Counseling and follow-up of exposed HCW.
8.25.12.6.1. The current Public Health Service (PHS) guidance recommends
prescribing medications as PEP for all occupational exposures to BBF.
8.25.12.6.2. The challenge to BBF exposure in the AE system is the HCW may not
be in a facility. They may be in flight, in a high threat forward location, or in a
temporary ERPS geographically separated from a fixed medical facility.
DAFI48-107V1 15 DECEMBER 2020 171
8.25.12.6.3. The PHS guideline has removed exposure codes. Contact the PMRC and
the VFS as soon as operationally feasible.
8.25.12.7. Initial Treatment. Reference AE Clinical Protocol - HCW BBF PEP.
8.25.12.7.1. Information to relay to the PMRC and VFS includes: Name, SSN,
date/time of injury/exposure, unit of assignment, phone, home phone, date of last
hepatitis B vaccine, and results of last antibody/titer screening, if known, source of
BBF and how the exposure occurred, protective items worn, volume, duration,
severity of exposure, and cite number of the source patient.
8.25.12.7.2. Determine demographics of the source patient with the VFS if possible.
8.25.12.7.3. The exposed HCW reports to a MTF as soon as possible after the
exposure, to address treatment options for the risk of hepatitis B virus exposure.
8.25.12.7.4. Administration of PEP for HIV is not delayed while waiting for test
results. If the source patient is determined to be HIV negative, PEP is discontinued,
and no follow-up HIV testing for the exposed provider is indicated.
8.25.12.7.5. PEP is most effective when begun as soon as possible after the exposure
and PEP becomes less effective as time from the exposure increases. Occupational
exposures to HIV is considered an urgent medical concern and treated immediately.
PEP is not justified for exposures that pose a negligible risk for transmission, thus
making the communication to the VFS critically important to establishing the need
for PEP.
8.25.12.7.6. HCW, who has experienced occupational exposure to BBF, receives
follow-up counseling, post exposure testing, and medical evaluation regardless of
whether they take PEP. The psychological impact of needle sticks or exposure to
blood or body fluid cannot be underestimated for the HCW. Exposed personnel are
advised to use precautions (e.g., use of barrier contraception and avoidance of blood
or tissue donations, pregnancy, and, if possible, breast-feeding) to prevent secondary
transmission, especially during the first 6–12 weeks after exposure. Providing HCW
with psychological counseling is an essential component of the management and care
of exposed HCW.
8.25.12.7.7. If PEP is used, HCW is monitored for drug toxicity by testing at baseline
and again 2 weeks after starting PEP. In addition, HCW taking antiretrovirals are
evaluated if any acute symptoms develop while receiving therapy. Exposed HCW,
who choose to take PEP, are advised of the importance of completing the prescribed
regimen.
8.25.12.7.8. The PIC and AECMs assess the situation and the condition of the HCW
in collaboration with C2 and the PMRC to determine if the mission continues or
diverts to a MTF capable of handling the situation.
8.25.12.7.9. Documentation includes: Completion of a patient safety reporting form.
The HCW maintains a copy of all paperwork and follows up with their local or home
base military MTF.
172 DAFI48-107V1 15 DECEMBER 2020
Chapter 9
PATIENT MOVEMENT PATIENT SAFETY PROGRAM (PMPS)
9.1. General. This chapter defines the requirements and responsibilities for the PMPS Program
as it applies to the AE system. The AMC AE PSP is aligned under the MEFPAK and Lead
Command authority of AMC/CC for the Aeromedical Evacuation mission. The AE PSP supports
Air Mobility Command’s Core mission of AE by promoting safety and the prevention of harm. It
also supports and is aligned under the USTRANSCOM Command Surgeon (SG) mission as the
DoD single-manager for global PM. The intent is to provide a structure and processes for
engaging all AE Units, patient staging personnel, MAJCOMs, and service components, DoD,
and Unified Commands to support and promote a culture of safety outlined in the objectives
below. The PMPS utilizes the web-based Joint Patient Safety Reporting system for inputting and
managing patient movement patient safety events. Additional patient safety resources are listed
in Attachment 2, A2.2.
9.2. Objectives:
9.2.1. Advance a culture of high reliability and patient safety (PS) throughout the AE patient
movement system.
9.2.2. Promote transparency, teamwork, and communication.
9.2.3. Establish policy/standards to incorporate PS initiatives at all levels.
9.2.4. Promote an open, receptive, and non-punitive event reporting environment.
9.2.5. Provide an ongoing and systematic approach for system improvement and risk
reduction.
9.2.6. Reduce potential or actual patient harm events.
9.2.7. Disseminate PS data and initiatives for ongoing learning and involvement.
9.2.8. Track and trend patient satisfaction within the AE system for purpose of
improvement/evidence-based practices.
9.3. Responsibilities.
9.3.1. TCSG. The USTRANSCOM PSP is outlined in USTRANSCOM Handbook 41-1.
9.3.2. Geographic Combatant Command (GCC). GCC responsibilities are outlined in
USTRANSCOM Handbook 41-1.
9.3.3. AMC/SG.
9.3.3.1. AMC/SG establishes clinical practice standards and clinical training
requirements and is responsible for the quality and safe delivery of medical care in the
AE system. AMC/SG is the repository and process owner for AE PSP data, trend
analysis, Medical Incident Investigations (MII), Root Cause Analysis (RCA), etc.
Responsible for quality and safe delivery of medical care in the AE system.
9.3.3.2. Appoints an AMC AE Patient Safety Program Director.
DAFI48-107V1 15 DECEMBER 2020 173
9.3.3.3. Collaborates with the TCSG to determine the appropriate level of review, CSA
or investigation of AE PS events based on type of event and the organizations involved.
Coordinates with DHA, Air Force Medical Readiness Agency (AFMRA), and
MAJCOM/SGs.
9.3.3.4. Together with TCSG, receives all investigation and CSA outbriefs and makes
final approval decisions on AE system related recommendations.
9.3.4. AMC/SG AE Patient Safety Manager (PSM).
9.3.4.1. Reports to the AMC/SG and is responsible for the management of the worldwide
AE PS Program. Activities include but are not limited to:
9.3.4.2. Ensures a comprehensive and integrated AE PS Program is maintained in
accordance with DoD PS principles. Coordinates with other safety programs such as
Crew Resource Management/Airman Safety Action Program to communicate issues.
9.3.4.3. Identifies actual and potential patient safety risks or trends for the purpose of
system improvement and risk reduction.
9.3.4.4. Coordinates/prepares instructions with TCSG, MAJCOM/SG, MAJCOM/A3
and functional experts for appropriate DoD and Air Force publications, SG Notice to
Airmen (NOTAM), FCIF, COPSA, and policy letters.
9.3.4.5. Reviews, classifies, and trends all AE reported events in JPSR Transportation
Command patient movement system and provides guidance to all theater and service
components based on data and trends. Any patient movement events involving PMRC or
other services are discussed with USTRANSCOM PSM for appropriate disposition.
9.3.4.6. Provides the AF/SG, AMC/SG and/or A3 and AE clinical working group with
trend analysis and recommendations for a course of action to prevent identified PS issues.
Serves as PS resource for all levels and theaters of personnel working within the AE
system.
9.3.4.7. Facilitates and assists USTRANSCOM Patient Safety with the initiation of fact
gathering, team selection, orientation of EPSI and CSA teams, setting up out briefs to
leadership and with follow-up of implementation of AE System related
recommendations.
9.3.4.8. Facilitates dissemination of AE “lessons learned” and PS initiatives through
TCSG, AMC/SG and AMC/A3.
9.3.4.9. Develops and teaches PSM training for AES’ and ERPS based on DoD PS
principles.
9.3.4.10. Maintains expertise in healthcare PS and incorporates those principles in the
AE PSP and serves as consultant and advisor to leadership on PS issues and concerns.
9.3.5. AMC/A3.
9.3.5.1. Communicates information to AMC/SGK regarding clinical trends in training
and evaluation.
9.3.5.2. Updates policy and operational guidance based on clinical and PS lessons
learned.
174 DAFI48-107V1 15 DECEMBER 2020
9.3.5.3. Acts as advisor and liaison to TCSG and AMC AE PS process improvement.
Member of the AE clinical working group.
9.3.5.4. Manages aircrew operationally related events submitted through the Aviation
Safety Action Program and/ or JPSR system.
9.3.6. Theater MAJCOM SG.
9.3.6.1. Responsible for oversight of the Command AE PS Program, actively supports
investigations, event reviews, and process improvement efforts within the theater and
across the system.
9.3.6.2. Appoints a command-level PSM. This role may be delegated to the squadron
level although authority and oversight is maintained at the MAJCOM level.
9.3.6.3. Notifies AMC/SG of any significant clinical AE events or any medical issues
requiring command surgeon action. All MDGs, PMRCs and Active Duty (AD) AES’ will
have access and respond to AE patient safety events in the JPSR involving their Unit. (T-
0). The command-level AE PSM requests access to view AE patient safety events in the
JPSR Transportation Command patient movement system.
9.3.6.3.1. Coordinates and works with TCSG and AMC/SG on the scope and
direction of investigation/level of review needed for significant events based on
classification of events (Table 9.1).
9.3.6.3.2. Provides all final investigation reports and event reviews to TCSG and
AMC/SGK for system-wide transparency and process improvement.
9.3.6.3.3. Participates in investigations and CSA (e.g., root cause analysis) outbriefs
to TCSG and HQ AMC/SG. Implements approved recommendations within
respective theater of operation and disseminates “lessons learned.”
9.3.7. Theater MAJCOM PSM.
9.3.7.1. Required for commands and theaters with owned or gained AE assets (even if
dual role). Responsible for managing the MAJCOM PMPS Program.
9.3.7.2. Works closely with the Theater PMRC PSM to maintain awareness of theater-
level events, trends, issues, and provides updates to MAJCOM SG.
9.3.7.3. Actively promotes and supports PS across the theater.
9.3.7.4. Acts as a MAJCOM/Theater advisor for AE PS requirements to unit level
programs and a liaison to the TCSG Director PMPS Program and the AMC/SG AE PSM.
9.3.7.5. Evaluates significant events in assigned theater to determine if an EPSI or CSA
(root cause analysis) is needed. Collaborates with TCSG PMPS Program Director and the
AMC/SG AE PSM to coordinate and conduct the investigation process.
9.3.7.6. Implements EPSI and CSA (root cause analysis) approved recommendations
within respective theater of operations and disseminates “lessons learned” to appropriate
communities.
9.3.8. Commander, AES/OIC/Senior Officer/Flight Commander of ERPS.
DAFI48-107V1 15 DECEMBER 2020 175
9.3.8.1. Fosters an organizational commitment and culture that promotes high reliability,
high quality patient care, collaborative teamwork, and communication. Supports and
encourages PS event and near miss reporting, event review, analysis, and prevention of
events that caused, or have potential to cause, patient harm during operational missions,
exercises, and training missions to include Aeromedical Readiness Missions (ARM).
9.3.8.2. Ensures local policies and procedures governing the management of the AE PS
Program are established and provide oversight of the program.
9.3.8.3. Appoints an AES PSM OIC or ERPS PS OIC and ensures member receives
TCSG and AMC/SG approved AE PS Manager training within six months of starting the
position. The AE Squadron PSM OIC is a minimum grade O3 and has at least 30 flying
hours experience. All active, ARC, and deployed AES’ and Staging units have a
designated patient safety manager or OIC.
9.3.8.4. Reviews Unit PSMs internal quarterly reports and elevates concerns or issues to
MAJCOM and AMC/SG AE PSM.
9.3.8.5. Reviews and approves Unit PS program appraisal of the past calendar year and
the annual plan for the new calendar year. This can be two separate reports or addressed
in one report. Ensures completion of the Annual Appraisal according to guidelines
(reference paragraph 9.3.9.12).
9.3.8.6. Defines an internal process for reviewing events involving the unit that are
submitted in the JPSR and other relevant events and ensures unit corrective actions are
identified and taken and follow-up is accomplished. Patient safety events involving the
unit are visible and actionable through the JPSR.
9.3.8.7. Ensures annual PS training is conducted for all members of the unit in
accordance with AFI 44-119.
9.3.8.8. Appoints members of unit-level AE CSA/RCA team as determined either locally
or by higher headquarters.
9.3.8.9. Ensures reporting of all information concerning significant events (typically
those classified as death, severe permanent or severe temporary harm) into the JPSR
system to the MAJCOM AE PSM, the AMC/SG AE PSM and the TCSG Director PMPS
Program.
9.3.9. PSM and PS OIC for AES and ERPS Units.
9.3.9.1. Responsible for administration of the unit PMPS program for either the AE
Squadron or ERPSS. Assists the Commander in promoting a strong culture of safety and
high reliability to eliminate preventable patient harm by implementing applicable DoD
patient safety and high reliability tools within the AES or ERPSS.
9.3.9.2. All AD AES PSMs and/or designees obtain a JPSR account for managing PS
events assigned to their unit to review/investigate. All AD ERPSS respond to AE PS
events as assigned by their MTF PSM. All ARC Staging UTCs follow PS reporting
guidance from their MAJCOM. A JPSR account can be obtained by first contacting HQ
AMC Patient Safety.
176 DAFI48-107V1 15 DECEMBER 2020
9.3.9.3. Provides unit training on how to report PS events utilizing the DD Form 2852 or
JPSR Worksheet and what information to include on the reporting form. The patient
safety event forms are then turned in to the operational AES or Detachment.
9.3.9.4. Ensures all harm events are reported to the Unit Commander as soon as possible
and submitted in the JPSR system within 24 hours of the event occurring. All other no
harm and unsafe condition type of events are submitted as soon as possible but not to
exceed five days of the event.
9.3.9.5. All AD PSMs will log into the JPSR System at a minimum, weekly to check for
events assigned to the unit to investigate and add input, contributing factors, and lessons
learned/corrective actions within seven days of the event being assigned. (T-2). Initiates
appropriate level of review, follow-up, and action as determined locally and/or by higher
headquarters.
9.3.9.6. Uses a locally developed coordination process to document review and
resolution of events by working with involved functional areas, units or agencies as
needed (Wing/OG/A3V/ A3T/NAF/MAJCOM, TPMRC, MDG, etc.).
9.3.9.7. Analyzes PS event data to identify trends, actual issues/concerns and takes
action to improve processes/reduce risk within the units’ span of influence or control.
Elevates, through the unit Commander, any issues/concerns beyond the units’ span of
influence or control.
9.3.9.8. Provides additional JPSR event information as requested by HQ AMC or
USTRANSCOM Patient Safety. These requests can be through the JPSR System or by e-
mail.
9.3.9.9. Maintains open communication on squadron/theater level issues with local
leadership, and when applicable, MAJCOM PMPS Program Manager, AMC/SG AE
PSM and TCSG Director PMPS Program.
9.3.9.10. Provides a quarterly report to the AES or MDG commander on unit patient
movement event trends, PS issues and follow-up on actions taken.
9.3.9.11. Provides ongoing feedback to unit personnel on PS issues, trends, and actions
or “lessons learned.”
9.3.9.12. Provides AE PS annual appraisal. At the end of each calendar year, the unit
prepares an appraisal signed by the unit commander of its PS program for that past
calendar year and submits it to AMC/SG AE PSM, through the respective MAJCOM.
Suspense for submission of this report is 1 February. At a minimum, the following areas
are addressed:
9.3.9.12.1. PS training statistics for the past year. Include total number personnel
trained/total number personnel requiring training. This includes initial training and
annual training. Briefly identify topics covered. Include an action plan to address
personnel not trained.
9.3.9.12.2. Provides a statistical review and analysis of the Unit’s patient movement
JPSR events in the JPSR System for the past year. Identifies issues or trends and local
actions taken. Identify and summarize any CSA (e.g., root cause analysis) conducted.
DAFI48-107V1 15 DECEMBER 2020 177
9.3.9.12.3. Describe local PS initiatives on how the National Patient Safety Goals
and AE System Patient Safety Goals were addressed.
9.3.9.12.4. Describe unit actions taken in response to any applicable SG NOTAMs,
COPSAs, FCIF and/or PS related policy memos in the past year.
9.3.9.12.5. Identify any PS concern(s) or area(s) for improvement beyond the unit’s
control (if any) and include recommendations for improvement.
9.3.9.12.6. All unit annual appraisals are reviewed by AMC/SG AE PSM. Data from
the appraisals may be incorporated into the AE/En Route Care Annual Patient Safety
Report. Any system trends, issues or concerns may be elevated thru the AE
governance structure with recommendations for course of action to prevent identified
AE PS issues.
9.3.9.13. ALL AES/ERPS Units input a minimum of 4 training JPSR Worksheet or DD
Form 2852 or events, per semi-annual period, into the TRAINING JPSR system for
quality assessment and audit by AMC/SG PSM.
9.3.10. AES and ERPS unit personnel.
9.3.10.1. AES personnel utilize the JPSR Worksheet or DD Form 2852 to report AE PS
events into the JPSR system and report all operational events into the Aviation Safety
Action Program (ASAP) program. AD ERPSS report AE PS events directly into the
patient movement JPSR web-based system. Only one patient safety issue per event report
is made. If there are multiple issues, multiple patient safety reports are input.
9.3.10.2. If equipment or supplies are involved in an event while on a patient, remove it
from the patient and tag it appropriately (reference paragraph 12.5) and turn it into the
appropriate agency. Contact AMC AE PSM for guidance with non-equipment supply
issues (mislabeled IV bags or medication bottles, etc.). Note: Do not clear the history or
data from any malfunctioning equipment (e.g., history, settings, volume infused) as this is
important to the Biomedical review of equipment.
9.3.10.3. Attends annual PS training taught by the unit PSM, incorporates PS initiatives
and alerts into practice and participates with event reviews or investigations conducted
for the purpose of system improvement.
9.3.11. MCD.
9.3.11.1. Responsible for in-flight medical mission management for the AE crew, ERCC
team members, MAs, and patients.
9.3.11.2. MCD reports all harm related and/or concerning patient safety events to C2
who then contacts the governing PMRC. During the end of mission report, MCD
completes and faxes necessary paperwork.
9.3.11.3. MCD/AECM complete the mission termination process in accordance with
AFMAN 11-2AEV3.
9.3.11.4. At the end of mission, submits completed DD Form 2852s or JPSR Worksheets
to Unit or Squadron PSM or through an en route Detachment supporting the mission for
entering into the JPSR web-based reporting system.
178 DAFI48-107V1 15 DECEMBER 2020
9.3.12. PMRC.
9.3.12.1. During mission, provides initial assistance and medical direction, as needed,
when notified of a patient safety event involving harm. Supports TCSG and AMC/SG in
reviewing or conducting an EPSI or CSA (e.g., root cause analysis) as required. Each
TPMRC identifies a PSM to assist in the following activities including but not limited to:
9.3.12.2. Notifies the following of any death or significant harm events concerning
medical issues within 24 hours of occurrence: TCSG patient safety office via e-mail to
transcom.scott.tcsg.mbx.patient-movement-safety-program@mail.mil. AMC/SG
patient safety office via e-mail to amc.sgk.ae_pt_safety@us.af.mil; and the
GCC/Theater SG.
9.3.12.3. TPMRC PSM obtains a JPSR live account for managing patient movement PS
events assigned to the TPMRC to review/investigate or provide additional information to
an event.
9.3.12.4. Provides all relevant documentation, information, and originals of any form
documenting validation, regulation, patient care, log entries related to a PS event for the
purpose of quality assurance protected PS reviews or investigations. Assists as needed in
obtaining copies of any paper AF Form 3899 medical records of the patient from the
receiving facility.
9.3.12.5. Identifies potential problem areas in patient regulation and validation through
analysis of data and review of internal processes.
9.3.12.6. Participates on EPSI and CSA (e.g., root cause analysis) teams.
9.3.12.7. Provides PM expertise and information/data to the TCSG Director PMPS and
the AMC/SG AE PSM upon request. Provides consultative support on PS issues to the
theater surgeon.
9.3.12.8. Provides PS training to all members of the TPMRC. Incorporates and
disseminates “lessons learned” from clinical AE investigations and patient safety alerts,
as applicable.
9.3.12.9. Initiates and participates in process improvement activities.
9.4. Patient Movement Event/Near Miss Reporting Process.
9.4.1. PMPS Event. An incident or condition that may or may not have resulted in harm to a
patient occurring in the AE system. This also includes “unexpected” changes in patient
status and events that could have, but did not reach the patient (e.g., close calls and unsafe
conditions).
9.4.2. PMPS event reporting boundaries. PMPS boundaries start with clinical and/or
administrative validation activities and end 24 hours after transfer of care at the final
destination MTF (civilian or military).
9.4.3. All patient safety events related to aeromedical evacuation patient movement,
regardless if in flight, on the ground or within the MDG, are entered into the JPSR web-based
system in the Transportation Command patient movement section.
DAFI48-107V1 15 DECEMBER 2020 179
9.4.3.1. Anyone throughout the En Route Care system can report a patient movement PS
event. AES personnel completes a DD Form 2852 or JPSR Worksheet and give the form
to a PSM or designee to enter the form into JPSR system. If PSM is unavailable to submit
into the JPSR in the required time frame (reference paragraph 9.4.3.2) any unit member
is able to submit into the JPSR. The reporting worksheet is available in TRAC2ES
Documents, on the AE website, or by contacting TCSG Director PMPS or HQ AMC AE
Patient Safety.
9.4.3.2. All events are entered as soon as possible. If a mission is in progress, harm
events (death, severe harm, moderate harm, mild harm) the VFS will be notified and the
event will be entered into JPSR system within 24 hours. (T-0). All other event
classifications (no harm, near miss, unsafe condition) will be entered within five days of
the incident. (T-0).
9.4.4. Do not document in the patient record that an event report was completed. Information
on the DD Form 2852 and JPSR Worksheet is protected by the Privacy Act and from
disclosure, except as specifically authorized, DoDI 6025.18 and DoDI 6025.13.
9.4.5. Guidelines for completing a DD Form 2852 or JPSR Worksheet are available in
TRAC2ES Documents, on the AFMRA and AE Patient Safety websites or by contacting the
TPMRC, TCSG Director PMPS, or AMC AE PSM.
9.4.6. When a DD Form 2852 or JPSR Worksheet is filled out and later entered into the
JSPR System, the original hardcopy form is and uploaded as a pdf file into the JPSR. At a
minimum this is completed for all PS events with a harm scale rating of death, severe harm,
moderate harm, mild harm, and no harm. Once the hardcopy form is uploaded into JPSR
system, it can be maintained in a secure manner for local data purposes or destroyed. In
addition to the JSPR Worksheet, any applicable documents helpful in
reviewing/understanding the event are also scanned as a pdf file and uploaded into the JPSR
event (e.g., PMR, copy of hardcopy AF Form 3899, AF Form 3899I, Patient Movement
Medication Record, AF Form 3899 doctor orders, memo of additional information
concerning the event detail).
9.4.7. Once an event is submitted into JSPR it is reviewed by USTRANSCOM and HQ
AMC AE PSMs who assign it to the identified involved unit. If the submitting unit is not the
involved unit, the submitting unit does not have access to the event in JPSR. If the submitting
unit has additional information after an event is submitted, notify HQ AMC AE PSM.
9.5. Event Degree of Harm.
9.5.1. Events are assigned a harm category to facilitate trending and analysis. Both the
degree of harm and duration of harm are assigned (reference Table 9.1 and 9.2).
9.5.2. The submitting unit indicates the initial classification. TCSG Director of the PMPS or
AMC/SG AE PSM make the final event classification determination.
Table 9.1. Degree of Harm.

Event Description
Classification
180 DAFI48-107V1 15 DECEMBER 2020
Death Pt unexpected death while in the AE en route care system up to

and including 24 hours after destination arrival.
Severe Bodily or psychological injury (including pain or disfigurement)
that interferes substantially with functional ability or quality of
life.
Moderate Bodily or psychological injury adversely affecting functional
ability or quality of life, but not at the level of severe harm.
Mild Bodily or psychological injury resulting in minimal symptoms
or loss of function, or injury limited to additional treatment,
monitoring, and/or increased length of stay.
No Harm Event reached the patient, but no harm was evident.
Near Miss Event did not reach the patient, either by chance or timely
intervention, but could have resulted in harm, or the potential for
harm, had it reached the patient. Also known as close calls or
good catches.
Table 9.2. Duration of Harm.

Permanent Harm that remains and is not expected to improve (e.g.,
not return to patient’s baseline).
Temporary Harm that is not permanent and expected to revert to
approximate normal (e.g., patient’s baseline).
Unknown Duration of harm is unknown at the time of
classification.
Not Applicable The type of event does not lend itself to a harm duration
classification (e.g., a near miss that does not reach the
patient)
9.6. Event Categories.
9.6.1. Event categories are determined by USTRANSCOM PS Director or HQ AMC PSMs
based on the main issue in the event. It is important the main issue is clear in the event
description.
9.6.2. Multiple events are reported in separate event reports. If there are more than one type
of event involving the same patient (e.g., meal issue and status change and equipment failure)
then a separate PS report for each event is required.
9.6.3. Examples of JPSR type of events to report within the patient movement system can be
found in Attachment 16. Other CY 2019 reporting changes are summarized in Table 9.3
Table 9.3. Reporting Changes.

Event Type Reporting Changes
Crew injuries Report in ASAP Reporting
Program
Civilian Facility Meals or Report only significant patient
anti-hijacking safety related issues in JPSR. AE
crews expect no meals or anti-
DAFI48-107V1 15 DECEMBER 2020 181
hijacking from civilian facilities

and take corrective actions.
Waivered Equipment Equipment with proper waivers do
not get reported
Aircraft emergencies Report in ASAP Reporting
Program. If a patient is involved,
then report in both JPSR and
ASAP but no patient ID data in
ASAP.
Baggage issues No reporting mechanism, handle at
local leadership level
EHR technical issues not Report to EHR Help Desk:
involving patient safety amc_ae_ehr@us.af.mil
Use of AE Clinical No PS reporting needed for AE
Protocol - Over the Clinical Protocol - Over the
Counter (OTC) Counter (OTC) Medication
Medication Administration use that responds
Administration to treatment (e.g., Tylenol for
headache) unless patient does not
improve.
9.7. Reporting Events Involving Unexpected Death, Permanent Harm, or Severe
Temporary Harm.
9.7.1. Notify executing C2/PMRC as soon as possible followed by reporting the event into
the JPSR System as described in paragraph 9.4 Note: Patient care and safety come first and
are managed before beginning the reporting process.
9.7.2. Within three hours of notification of an unexpected death, permanent or severe
temporary harm event, the regulating TPMRC collects and reviews all internal PMRC
records (e.g., TRAC2ES audit history, PMR, all internal notes, daily log entries, and mission
tracking records) regarding validation prior to movement. The TPMRC notifies
USTRANSCOM and HQ AMC Patient Safety and provide collected information as
requested by USTRANSCOM Patient Safety.
9.7.3. Upon notification of an unexpected death, permanent or severe temporary harm event,
the USTRANSCOM and HQ AMC Patient Safety representatives collates reported event
details into an I-SBAR summary and submit to respective leadership for awareness along
with recommended actions.
9.7.4. A patient movement PS Event involving unexpected death, permanent harm or severe
temporary harm can result in a patient movement CSA, EPSI, or other defined review. The
GCC/Theater SG in conjunction with USTRANSCOM/SG, decides the level of investigation
or review necessary for the event. Either investigative process is initiated within 15 days of
the event notification with a report completed within 120 days of the event notification.
9.8. PM Comprehensive Systematic Analysis (CSA).
9.8.1. A PM CSA is structured similar to a Root Cause Analysis (RCA) and utilizes team
members from each of the involved Units. The goal of the CSA is to identify system factors
182 DAFI48-107V1 15 DECEMBER 2020
that led to the event and solutions to prevent or reduce the likelihood of similar events in the
future. The product of the Event Review is a written team report consisting at a minimum of
a timeline of events across the continuum, identified contributing factors with root causes,
and an action plan designed to eliminate or minimize the root causes of the event and
improve safety of the process. The focus is on human factors, processes, and systems rather
than individual blame. Any concern for professional competence is identified by the
leadership for appropriate SOC review separate from the event review process.
9.8.2. May be considered for any type of event regardless of harm but is considered for all
events involving unexpected death, permanent and severe temporary harm events.
9.8.3. Authority: Service or GCC/Theater SG, USTRANSCOM/SG, or HQ AMC SG can
direct a PM System CSA involving multiple units. Local unit level leadership may also
conduct a local CSA as determined.
9.8.4. The CSA report is a quality assurance document and is exempt from discovery or
further disclosure except as specified in DoDI 6025.13. This is stated in the CSA report.
9.8.5. The team composition is determined by the type and severity of the event and is
comprised of selected subject matter experts as determined by the event.
9.8.6. TCSG Director of the PMPS and AMC/SG AE PSM provide CSA Team training and
assist the team with the process.
9.8.7. For system level event reviews, the event review team sends the final written report
with findings, recommendations to the respective impacted Agency Safety Departments to
include: GCC/Theater, Service, USTRANSCOM, and HQ AMC/SG AE PSM within 120
days of being directed to conduct an event review.
9.8.8. Leadership who directed the event review, determine requirements for a formal out
brief.
9.9. PM External Patient Safety Investigation (EPSI).
9.9.1. A formalized structured investigation process with a primary purpose to find out how
the system contributed to the adverse outcome by thoroughly investigating the facts in a non-
punitive way. The goal is to learn from the event and improve healthcare by recommending
system changes to reduce the risk of recurrence, thereby decreasing harm to patients. A
PM/AE MII may involve multiple geographic locations, services, and systems of care, which
may complicate and significantly lengthen the investigative process.
9.9.2. Authority: TCSG, AMC/SG, or GCC/Theater SG may direct a PM EPSI. Upon
initiation, the TCSG, as the single manager for patient movement, takes the lead for all EPSIs
within the AE System involving multiple units.
9.9.3. The EPSI report is a quality assurance document and is exempt from discovery or
further disclosure except as specified in DoDI 6025.13.
9.9.4. The team compliment is selected by TCSG and AMC/SG. If AFRC/ANG AECMs are
involved, the respective MAJCOM identifies contacts for appropriate team representation.
DHA/Service Patient Safety along with TCSG and HQ AMC Patient Safety provide EPSI
Team training.
DAFI48-107V1 15 DECEMBER 2020 183
9.9.5. All DoD Reportable Events (defined in DHA PM 6025.13), will be evaluated for
either a CSA or EPSI. (T-0). An EPSI may be accomplished for, but not limited to, the
following types of events:
9.9.5.1. Any event or series of events which in the opinion of GCC/Theater SG,
USTRANSCOM/SG, or HQ AMC/SG, either caused, or could cause, serious injury or
death. All events (particularly A, B, C) are evaluated for the requirement or need of an
event review process (MII vs Event Review). At a minimum, an appropriate level of
review is completed on all sentinel events (as defined by The Joint Commission and
DoD). The following events may warrant a MII (list is not all-inclusive):
9.9.5.2. Incidents where a full objective evaluation cannot be accomplished by an
internal CSA team.
9.9.5.3. Incidents with media attention or of a concerning nature, and incidents with
high-level interest.
9.9.5.4. Patient suicide, attempted suicide, or self-harm resulting in serious disability.
9.9.5.5. Hemolytic transfusion reaction involving administration of blood, or blood
products having major blood group incompatibilities resulting in permanent or severe
temporary harm or death.
9.9.5.6. Any event resulting in unanticipated death or major permanent loss of function,
not related to the natural course of the patient’s illness or underlying condition.
9.9.6. The final written report with timeline, findings, and recommendations is forwarded to
the respective impacted agency safety departments, to include as required, GCC/Theater,
Service, USTRANSCOM and HQ AMC within 120 days of event notification.
9.9.7. A formal out brief is required. Attendees to the out brief are determined by the TCSG
and AMC/SG. At a minimum, AFMRA/CC and the involved Theater/SG will be a part of the
out brief. (T-0). When possible, if ARC personnel are involved in the event, the ARC
leadership are contacted for team inclusion.
9.10. Clinical Operations Patient Safety Alert (COPSA).
9.10.1. A COPSA is a patient safety alert issued by USTRANSCOM SG and/or HQ
AMC/SG in order to address a critical patient safety trend or a high-risk concern. The
recommendations and guidelines are followed by personnel in the AE System. The specific
target audience are identified in the COPSA and the directions and guidelines are followed
by personnel in the AE system.
9.10.2. Current COPSAs are available on the AFMRA Patient Safety Website or through the
TRAC2ES Documents section. Contact USTRANSCOM or HQ AMC AE Patient Safety
website for questions regarding the COPSA.
9.10.3. Upon release, DoD MTFs, AES PSMs and ERPS PS OICs immediately work with
their leadership to implement recommendations and ensure all personnel have reviewed and
are familiar with the COPSA.
184 DAFI48-107V1 15 DECEMBER 2020
Chapter 10
MISSION IRREGULARITIES
10.1. Cabin Altitude Restriction.

10.1.1. Cabin altitude restrictions may be required with clinical conditions associated with
retained air such as head injuries, eye injuries, or decompression injuries. If an altitude
restriction is required, it is identified on the patients PMR and documented on the EHR or AF
Form 3899 prior to validating the patient.
10.1.2. Cabin altitude restriction could lengthen the flight time and increased turbulence may
occur. The PRMC communicates the cabin altitude restriction to the governing AOC.
10.2. Medical Emergency/Change in Patient Status.
10.2.1. In the absence of direct physician contact/supervision, AECMs immediately start
interventions in accordance with AHA or equivalent, TNCC if available, and DHA/J7
Education and Training guidelines. All IV solutions are either LR or NS.
10.2.1.1. FN/AET refers to AFMAN 11-2AEV3 for operational information. ERPS
personnel follow MTF guidelines.
10.2.1.2. Do not use any personal identifying information when transmitting medical
information. Note: For patient related issues, the cite number is used to protect patient
privacy.
10.2.2. Be ready to communicate demographical and medical information quickly and
succinctly. Also, report any treatment/intervention and the outcome. Be prepared to
request/receive orders, mission deviation/divert, to expedite meeting patient and mission
requirements.
10.2.3. If instructed to divert or expedited landing is required, ensure proper off-load
message using AF Form 3858, Aeromedical Evacuation Mission Offload Message, is
provided to the airfield with equipment and personnel requirements.
10.2.4. Anytime a patient is removed from a flight or the staging facility for clinical
evaluation or a significant change in status, the MCD/AECM/Chief Nurse notifies C2 who
notifies the governing PMRC and complete DD Form 2852 or JPSR Worksheet.
10.2.5. A qualified member of the medical crew accompanies the patient to the MTF, if
needed, maintaining the same level of care and providing report to the MTF’s accepting
privileged provider.
10.2.5.1. In some instances, a civilian ambulance responds to transport the patient to the
MTF, and the local memorandum of agreement may not permit military medical
personnel to ride in the ambulance.
10.2.5.2. If a member of the medical crew cannot accompany the patient to the MTF,
report is provided to the accepting MTF privileged provider via radio or telephone. The
cite number is used on the radio or telephone to identify the patient due to HIPAA
regulations.
DAFI48-107V1 15 DECEMBER 2020 185
10.2.5.2.1. The original AF Form 3899 and other medical records accompany the
patient to the MTF.
10.2.5.2.2. Whenever possible, the MCD/AECM ensures a copy of the AF Form
3899/DD Form 602, Patient Evacuation Tag, is faxed to the PMRC. If the AF Form
3899 cannot be copied, provide detailed information on AF Form 3829, and complete
DD Form 2852 or JPSR Worksheet.
10.3. Death In-flight/Do Not Resuscitate (DNR).
10.3.1. For Death in Flight reference AFMAN 11-2AEV3.
10.3.2. DNR orders. AE/ERPS can accept DNR patients with approval from the VFS and
matched with the appropriate level of care. If a patient death is anticipated while a patient is
in the AE system and a decision has been made not to resuscitate, an AF Form 3838 is
completed and attached to AF Form 3899. Attending physicians addresses DNR status of
peacetime AE patients facing imminent death or classified as very seriously ill, recognizing
the stresses of flight may pose significant risk for precipitating death. The VFS reserves the
authority to deny movement by AE of peacetime patients for whom AE poses an
unacceptable risk of death or injury. Patients may also be moved for organ donation or family
requests when a DNR would not be appropriate.
10.3.2.1. The originating physician provides the following documentation before flight:
10.3.2.1.1. A completed AF Form 3838.
10.3.2.1.2. “Do Not Resuscitate” order on the EHR or AF Form 3899 is not written
more than 72 hours before the originating flight.
10.3.2.1.3. Prior to flight, verify the order with the patient and/or the patient’s family.
10.3.3. Countermeasures aim to reduce the risk of precipitating the onset of death to the
greatest extent allowed by mission constraints. The goal of AE for DNR patients is to deliver
them successfully and safely to the requested destination ensuring highest level of comfort
possible. Consequently, supportive supplemental oxygen therapy, IV hydration to combat
dehydration, en route MAs, and a cabin altitude restriction is not automatically ruled out
because the patient is a “DNR.”
10.4. Mission Delays.
10.4.1. Refer to AFMAN 11-2AEV3. The medical crew is responsible for the welfare,
safety, and clinical care when patients are deplaned for comfort during ground operations.
Patient care continues without degradation through the delay; on the aircraft if delay is
expected to be less than one hour or in the nearest medical facility if the delay exceeds three
hours. MTF/ERPS personnel assist if available.
10.4.2. Medical considerations during mission delays are: Medical orders for treatments,
medications and diet if applicable. Before continuing mission after a delay, ensure enough
medication, supplies (if available), and nourishment are available for remainder of mission.
10.4.3. If a mission delay occurs while the patient is under the responsibility of the ERPS
personnel, the ERPS personnel in collaboration with the AECM, evaluate the best location
for the patient. (e.g., remain on the AMBUS or return to the staging area).
186 DAFI48-107V1 15 DECEMBER 2020
10.5. Medical Delays.

10.5.1. Medical hold. In the event of changes in the patient’s condition, the flight surgeon
may place a patient on medical hold, not to exceed 72 hours. Patients with status changes
may require admission to a MTF whereupon the flight surgeon arranges for hospitalization
and a continuation PMR is initiated. ERPS personnel notifies the PMRC of the interruption
of PM.
10.5.2. In the event the MCD/AECM/Chief Nurse is concerned a patient is at significant risk
for flight or requires care beyond the scope of the AE crew or ERPS, the MCD/AECM or
Chief Nurse notifies C2 who then contacts the governing PMRC for additional MAs, support,
or re-evaluation. Depending on the contingency/tactical environment, refusing a patient for
flight may not be a viable solution.
10.6. In-Flight Refueling Considerations.
10.6.1. Refer to AFMAN 11-2AEV3.
10.6.2. During mission planning if in-flight refueling is required, the VFS approves.
10.6.3. Patients prone to motion sickness (e.g., pregnancy, GI disturbances), anxiety, and
pain from surgical or orthopedic injuries may require medication 20-30 minutes prior to
refueling.
10.6.4. Patients with head and spinal injuries, and those requiring advanced life-support, are
reassessed just prior to refueling.
10.7. En Route Diversions.
10.7.1. If a request for diversion, unrelated to patient needs, be received, and the AECM
determines this would place a patient(s) in jeopardy, immediate communication is established
with C2. The airlift agency contacts the governing PMRC to discuss and resolve the
situation. The MCD/AECM is responsible for determining what is beneficial for, or
detrimental to patients on board.
10.7.2. All patients on the mission are briefed on the change in itinerary and the reasons for
diversion.
10.7.3. AECMs assess equipment, medications, supplies, and nourishment for patient care
due to diversion.
10.7.4. If available, Patient Staging personnel assist, as necessary.
10.8. Scheduled and Unscheduled RONs.
10.8.1. Refer to AFMAN 11-2AEV3.
10.8.2. AE missions may require either scheduled or unscheduled RON stops. MTF
commanders at locations where RONs occur are responsible for the care of patients, securing
medical records and narcotics.
10.8.3. RON in the MTF or other facilities. If patients need to RON in the MTF or other
agency while transiting the AE system, they are not be formally admitted to the MTF. The
MTF flight surgeon, or designee, manages the medical care of such patients and reaffirms
DAFI48-107V1 15 DECEMBER 2020 187
their readiness for flight. Patients in RON status at a civilian medical facility may be
admitted, but the ERPS retains them administratively as ERPS RON patients.
10.8.4. Unscheduled RONs (reference AFMAN 11-2AEV3). The AECM coordinates with
C2 and the governing PMRC for assistance with facility points of contact to assure patient
needs are met.
10.8.5. MTFs at both scheduled and unscheduled RON stations are required to:
10.8.5.1. Assist with deplaning and enplaning patients.
10.8.5.2. Admit and assign patients to the MTF (civilian or military) or billeting facility
as appropriate.
10.8.5.3. Provide food/meals for the patients.
10.8.5.4. Prepare and manage records.
10.8.5.5. Evaluate and maintain the continuum of care.
10.8.5.6. Provide medical supplies, medications, and nourishment for the rest of the AE
mission.
10.9. Patients Requesting Release from the Aeromedical Evacuation System.
10.9.1. Refer to AFMAN 11-2AEV3. AECMs/ Patient Staging personnel document patient’s
condition on the EHR or AF Form 3899 prior to the patient being released.
10.9.2. AECMs/ Patient Staging personnel require the patient or guardian complete AF Form
3841, Certificate of Release.
10.10. Prisoner-patients.
10.10.1. If a prisoner-patient becomes ill or injured during flight, AECMs immediately give
care within scope of practice. The AECM contacts C2 and the C2 agency contacts the
governing PMRC as soon as possible to notify and receive orders and any other operational
direction (reference AFMAN 11-2AEV3).
10.10.2. The responsibility of the clinician is to provide safe clinical support during
transport.
10.10.3. Clinicians refrain from stating names, dates, times, or locations.
10.10.4. The guard of the prisoner may consider blindfolding the prisoner-patient if
indicated for personnel safety.
10.10.5. When possible the prisoner-patient is assigned one caregiver.
10.10.6. When meals or snacks are provided do not allow handcuffs to be released except for
ROM. At the guard’s discretion, the blindfold may be removed during meals. If meals are
provided with no visual blind, only the direct caregiver and guard are with the patient.
10.10.7. Prisoner-patients are treated as humanely as possible; all treatment is accomplished
in coordination of the guard.
10.10.8. Offer toileting and liquids every two hours. The guard assists to the bathroom. The
clinician monitors the prisoner-patient for safety and care only and assists as clinically
required.
188 DAFI48-107V1 15 DECEMBER 2020
10.10.9. The prisoner-patient will be the last to enplane and first deplaned. (T-1).
10.10.10. If possible, attempt to seclude the patient away from other patients.
10.11. Unaccompanied Minors/Incompetent Patients.
10.11.1. Any unaccompanied minor, under the age of 18, or any unaccompanied non-active
component patient who is incapable of directing their own care, will have an applicable
power of attorney, attached to the DD Form 602 or AF Form 3899. (T-0). The PMRC;
coordination with the originating MTF, is responsible for obtaining consent before
manifesting on AE missions.
10.11.2. Minors under the age of 18 will have an NMA. (T-0).
10.12. Conflict Resolutions.
10.12.1. Conflicts are resolved at the lowest level possible prior to elevating to C2.
10.12.2. If AECMs or ERPS personnel experience conflicts with a patient in the AE system,
contacts C2, who notifies the governing PMRC.
10.13. Credentials Considerations.
10.13.1. All registered nurses (RN) and medical technicians are familiar with credentialing
standards of nursing practice as described in current texts and references listed in this AFI.
The AECMs, specialty team members, Patient Staging personnel and any other MAs have a
responsibility to notify the MCD/AECM or Chief Nurse of all incidents, accidents, and
potential legal concerns detected during the mission. Such matters are carefully documented
as close to the occurrence as possible in accordance with AFI 44-119.
10.13.2. The MCD/AECM is responsible for identifying and elevating the above issues to
C2 and PMRC. The PMRC ensures notification to AMC/SG.
10.13.3. Clinicians are subject to adverse clinical action in response to a threat to patient
safety under DHA-PM 6025.13.
10.13.4. In the event a patient or attendant is injured while in the AE System, the AE/ Patient
Staging personnel document the injury and care rendered on the patient’s medical record.
Complete and forward a DD Form 2852 or JPSR worksheet to the unit patient safety
manager. Document occurrence on AF Form 3829. These two forms are protected from
disclosure under DoDI 6025.13 and are not included in the patient’s record.
10.13.5. Special considerations for patients who are seriously ill and those at significant risk.
The RN may sign a document as required on behalf of an unconscious, incompetent or
infectious patient, if physically unable. When signing for the patient, indicate “for
unconscious patient, John Doe.” For other patients, an entry of “patient unable to sign” may
be made. Two witnesses sign the form in both instances.
10.14. Engine Running Off/On Loads (ERO).
10.14.1. Refer to AFMAN 11-2AEV3. If an ERO is required, patient preparation includes:
Eye protection, hearing protection, and securing all medical equipment or tubing
accompanying the patient.
DAFI48-107V1 15 DECEMBER 2020 189
10.14.2. Explain to the patients what they can expect during this enplane/deplane procedure
to minimize their anxiety.
10.15. No and Low Light Conditions.
10.15.1. Mobility aircraft used for AE typically provide poor to fair lighting for patient care.
Flashlights or headlamps may assist with lighting conditions. Certain circumstances may
require night vision goggle compatible lighting. Follow pilot in command, and/or loadmaster,
boom operator guidance for appropriate lighting color (red, green, blue).
10.15.2. If care is indicated during low or no light conditions, use green lamps (flashlight or
headlamp) unless otherwise directed by PIC. Explain situation to patients to minimize
anxiety.
10.16. Service Animals and Emotional Support Animals.
10.16.1. Service animals are working animals, not pets. Service animals are individually
trained to perform specific tasks for people with disabilities such as guiding people who are
blind, alerting people who are deaf, pulling wheelchairs, alerting/protecting a person who is
having a seizure, and/or performing other special tasks.
10.16.2. Emotional support animals are companion animals that provide therapeutic benefit,
such as alleviating or mitigating some symptoms of the disability, to an individual with a
mental or psychiatric disability. Emotional support animals are typically dogs and cats but
may include other animals.
10.16.3. A service/emotional support animal is allowed to accompany a passenger/patient
with a disability within the cabin on DoD aircraft or within Patient Staging area. Commercial
aircraft chartered by DoD, or on behalf of DoD, may be subject to provisions of 14 C.F.R. §
382.117, Must carriers permit passengers with a disability to travel with service animals?
10.16.4. Service/emotional support animals may be accommodated on other aircraft, subject
to reasonable limitations required by configuration of aircraft and/or operational necessity.
10.16.5. Due to an animal's weight/size, state and foreign country restrictions may limit
transport of service animal within the cabin and/or cargo hold.
10.16.6. Service/emotional support animal are properly harnessed or leashed.
10.16.7. To avoid creating a safety hazard, service/emotional support animals do not
obstruct the aisles.
10.16.8. Service/emotional support animal will be permitted to accompany passenger in all
areas in which persons without disabilities are normally allowed to go. (T-0).
10.16.9. If a service/emotional support animal cannot be accommodated at a seat location of
passenger with a disability, offer the passenger the opportunity to move with the animal to
another seat location where the animal can be accommodated. A seat will not be booked for a
service/emotional support animal. (T-0).
10.16.10. The handler/patient with the service/emotional support animal is responsible for
all the needs of the service/emotional support animal including food, water, and toileting.
10.16.11. Certain unusual service/emotional support animals pose unavoidable safety and/or
public health concerns and may not be transported (e.g., livestock, snakes, other reptiles,
190 DAFI48-107V1 15 DECEMBER 2020
ferrets, rodents, and spiders). The need for the animal to accompany a patient is evaluated on
a case by case basis by the VFS.
10.16.12. Service animal certification documentation is in accordance with USTRANSCOM
Handbook 41-2.
10.16.12.1. PMRC, in coordination with the sending MTF, ensures all documentation is
complete and present.
10.16.12.2. Service animal removal from PM conveyance. If the owner does not control
the animal, or the animal poses a threat to health or safety of others, every effort is made
to mitigate the problem before excluding animal from terminal area or aircraft cabin.
10.17. Military/Government Working Dogs. Are authorized transport on all DoD missions
(reference AFMAN 11-2AEV3).
10.18. Passenger Requiring Medical Attention.
10.18.1. Passenger, crewmember, or medical personnel may become ill, injured or otherwise
become a patient.
10.18.2. In the event a passenger or crewmember becomes ill/injured during any type of AE
mission, treat the medical emergency with AHA or equivalent, TNCC if available, and
DHA/J7 Education and Training guidelines.
10.18.2.1. The AECM notifies C2 who then contacts the governing PMRC. Be prepared
to accept verbal orders from the VFS.
10.18.2.2. If the ill/injured individual is in a crew position, remove them from the crew
position and cover the duties as appropriate. Move to a litter if necessary.
10.18.2.3. If the ill/injured individual is a passenger, move to a litter if necessary.
10.18.2.4. Initiate an EHR or AF Form 3899 to document any treatment provided and the
patient’s response/outcome to the treatment.
10.18.2.5. If this is an operational mission, adjust the AF Form 3830 and AF Form 3829
(or TRAC2ES generated product) to account for an additional patient. If this is an ARM
mission, C2 directs required documentation. Complete a JPSR worksheet or DD Form
2852 fully outlining circumstances leading to event, interventions, and outcomes for both
operational missions and ARMs.
10.18.2.6. At mission termination, ensure the patient’s care is turned over to the
responding emergency services or is seen by an appropriate medical provider. AECMs
follow up with a flight surgeon.
10.18.3. If the ill/injured individual is staging personnel, treat the medical emergency in
accordance with AHA or equivalent, TNCC if available, and DHA/J7 Education and
Training guidelines. (Call local EMS in this situation) and remove from the patient care area.
DAFI48-107V1 15 DECEMBER 2020 191
Chapter 11
POST-MISSION PROCEDURES
11.1. Post-Mission Responsibilities. AECMs are required to complete tasks for mission
termination in accordance with AFMAN 11-2AEV3. The AECMs ensure:
11.1.1. All medical documentation is completed and properly dispensed.
11.1.2. Patient transfer report and care for inpatients is given to a same or higher level of
care provider.
11.1.3. Outpatients regulated as PAX (are not patients) and may be dispositioned to any
medical technician, nurse, family member or military personnel as designated by receiving
facility. AE is transporting only.
11.2. AE Patient and Customer Satisfaction Survey.
11.2.1. The AE system requires a process, established by AMC/SG, to solicit patient
feedback and comments. The AE Patient and Customer Satisfaction Survey is completed
towards the end of mission with reasonable time to collect prior to completion of patient
handoff. The handling during distribution and collection preserves the anonymity of the
patient (e.g., utilize an envelope to manage the survey forms). The patient may choose to
apply their name to the survey (reference Attachment 17).
11.2.2. AMC/SGK develops and updates the AE Patient and Customer Satisfaction Survey,
as needed, as well as identify/provide a web-based system for entering data.
11.2.3. AESs conducting operational missions distributes surveys to patients and attendants
on flights greater than 90 minutes.
11.2.3.1. This requirement may be impractical during contingency operations.
11.2.3.2. Each AES identifies an office responsible for reviewing all surveys for trends
and identified concerns. The AES contacts patients and customers requesting a response
to comments.
11.2.3.3. Completed surveys are input into the identified survey website by each AES
within 1 week of completing the operational mission.
11.2.3.4. Survey data, comment overviews, return calls and actions taken are reported
and recorded as part of the quarterly AES/MTF Executive Management Meeting minutes.
11.2.3.5. Notify AMC/SGK with concerns related to customer survey trends.
11.2.3.6. The AES identifies and implements local training requirements to ensure a
successful patient and customer satisfaction program. Notify AMC/SGK via email
(amc.sgk@us.af.mil) of local interventions, outcomes or process improvements based on
an overall “Dissatisfied” survey or inputs requiring action.
11.2.3.7. In garrison or permanent staging facilities, utilize the host MTF customer
satisfaction surveys. Deployed ERPS are not required to conduct patient satisfaction
surveys.
192 DAFI48-107V1 15 DECEMBER 2020
11.3. AMC Reviews And Analyzes AE System Surveys And Report Trends. AMC reviews
and analyzes AE system surveys and report trends and outcomes to the Total Force Aeromedical
Evacuation Clinical Working Group.
11.3.1. Reports includes outcomes from unit level interventions and/or process
improvements.
11.3.2. Reports include qualitative and quantitative information and provide
recommendations for improvement.
DAFI48-107V1 15 DECEMBER 2020 193
Chapter 12
MEDICAL LOGISTICS
12.1. MEFPAK.
12.1.1. AMC/SG is the MRA for Patient Staging and Aeromedical Evacuation capabilities.
They develop and maintain materiel requirements, TTPs, training platforms and provide
operational oversight.
12.1.2. AMC/SG is the MRA and Patient Movement Item Program Management Office for
the global PMI program. AMC/SG is responsible for the development/maintenance of the
PMI CONOPS, funding, management direction, oversight in support of PMI Centers, and
PMI operational support, to include en route care training platforms.
12.1.3. Personnel with questions regarding the PMI program contact AMC/SGXM at 1-877-
286-1931, DSN: 312-779-6952 or commercial 618-229-6952 or email:
hqamcpmi@us.af.mil.
12.2. PMI Asset Tracking System (PMI-ATS).
12.2.1. The PMI-ATS is the joint tool for asset tracking and essential for timely AE
equipment recycle support to prevent degradation of forward element medical capability.
Guidance for PMI is in JP 4-02 and AFMAN 41-209. Medical personnel are familiar with the
many aspects of the Theater’s PMI program, to include what is safe to fly certified,
obtaining, storing, maintenance, tracking, and recycling practices of the PMI commodity.
12.2.2. PMI-ATS tracking. All personnel working in PMI Centers, theater PMI Cell, ERPS
units, and AE units will scan all PMI equipment in their AOR in as Ready/Out/quality
assurance (QA) as applicable. (T-2). PMI equipment is routinely scanned while in the unit
and each time it moves or changes category. Follow guidelines established in PMI Tracking
Procedures for Center Operations and PMI Tracking Procedures for Ground Operations. Any
unit receiving PMI is responsible for scanning PMI “in” in order to maintain in-transit
visibility of PMI and scanning PMI “out” when recycling equipment back into the PMI
system. Before returning the equipment to the PMI system, the receiving facility/ERPS is
responsible for cleaning PMI items in accordance with AFI 44-108.
12.2.3. Training. All personnel working in PMI Centers, theater PMI Cell, ERPS units and
AE units will complete PMI training (one-time requirement) on the JKO website, US026-
PMI-ATS. (T-2). Once logged in, select “Course Catalog” and search for “PMI-ATS,” then
select “PMI-ATS Overview and Basics Training.” (T-2). Exception: PMI-ATS training is
not required for 1C0X2, 3D1X3, 3F2X1, 8F000 or 17D3X.
12.3. PMI Levels.
12.3.1. PMI center levels are found in allowance standard 887P and managed by
AMC/SGXM. PMI levels for deployed locations are established by the Combatant
Commander’s SG OPLANS in coordination with AMC/SGXM. Initial quantities of PMI are
pushed to AE Hub location sending facilities/ERPS who maintains initial quantities of
approved PMI in appropriate medical assemblages. MTFs should not assume or plan for
shortfalls of PMI being satisfied by designated PMI centers/cell.
194 DAFI48-107V1 15 DECEMBER 2020
12.3.2. During peacetime, special equipment can be provided by the AE system if the
referring MTF coordinates with the appropriate PMRC at the time the patient is reported for
transportation, and safe-to-fly PMI equipment is identified in the PMR for AE to hand carry.
At other times, the referring facility works with the designated supporting theater PMI lead to
establish local policies/procedures and maintain prepositioned levels of PMI equal to three
(3) days of expected patient flow in accordance with TCSG and AMC/SGXM guidance.
12.4. Equipment Responsibility.
12.4.1. The host medical equipment maintenance activity provides organizational
maintenance for all AE/ Patient Staging medical equipment as outlined in AFI 41-201,
Managing Clinical Engineering Programs and AFMAN 41-209. This includes initial
inspections, preventive maintenance inspections, calibrations, repairs, modifications, incident
investigations, equipment defect reporting, and disposal.
12.4.2. All medical equipment coming from the staging or originating facility accompanying
a patient is preflighted in accordance with AE Medical Equipment Compendium or the
equipment operating manual to ensure all components are present and the unit is
operating/functioning correctly. The PMI program is outlined in JP 4-02 Appendix B, and
AFMAN 41-209.
12.4.3. All AE certified and PMI equipment will have the AF Form 4033, PMI/AE
Certification Label, and the DD 2163, Medical Equipment Verification Certification or
AFTO Form 394 TMDE Certification. (T-1). The medical equipment maintenance activity
will ensure AF Form 4033 is affixed to each AE or PMI medical equipment item certified for
flight. (T-1). Biomedical maintenance individuals performing specific calibration or
certification procedures will affix a completed DD 2163, on the item. (T-1).
12.4.4. Maintenance assistance for equipment repairs beyond the capability of the host MTF
maintenance activity are obtained from the regional medical equipment repair center
(MERC) or designated deployed biomedical maintenance repair activity. The regional
MERC or designated deployed biomedical maintenance repair activity provide intermediate
maintenance for all AE/Patient Staging medical equipment. This includes support for
organizational maintenance activities, special maintenance actions, and quality assurance
actions, as required.
12.4.5. The medical logistics section with the AES/ Patient Staging works with host logistics
account/Medical Equipment Management Office (MEMO)/Biomedical Equipment
Technician (BMET) to ensure compliance/maintenance is completed and recorded on DD
Form 2163, affixed to the equipment.
12.4.5.1. This includes establishing procedures to ensure defibrillator batteries are
properly conditioned and annotated, ensuring proper operation and use of equipment,
cleaning, minor operational adjustments, and replacement of consumable accessories.
12.4.5.2. AES/ Patient Staging ERCC team units in non-deployed status ensure their unit
owned equipment is maintained on unit assigned Defense Medical Logistics Standard
Support accountable records. Deployed PMI equipment accountability is maintained on
AMC SG FM4444 deployed MEMO account records.
DAFI48-107V1 15 DECEMBER 2020 195
12.4.6. PMI and AE/Patient Staging equipment calibration requirement date will not be
exceeded during the planned mission scenarios. (T-1). These dates are recorded on the DD
Form 2163, affixed to the equipment, and updated in the PMI-ATS system maintenance date
field.
12.4.7. PMI and AE/Patient Staging equipment will be made available for preventive
maintenance inspections and calibration verification as required by the local BMET. (T-1).
12.4.8. Maintained in mission-ready status, to include clean, calibrated, charged, and with
one complete set of required accessories.
12.5. Equipment Malfunction/Failure.
12.5.1. If equipment malfunction/failure occurs during an operational mission, the
MCD/AECM ensures the following paperwork/actions are accomplished:
12.5.1.1. When malfunctioning equipment is identified and removed from a patient,
assess the patient for any harm. Do not clear any settings from the malfunctioning
equipment. This aides biomedical maintenance in their investigation.
12.5.1.2. Complete AF Form 4449, En Route Care Equipment Malfunction Report Tag.
(reference Attachment 18). If unavailable, complete AFTO Form 350, Reparable Item
Processing Tag.
12.5.1.2.1. Upon arrival to home station, immediately send tagged equipment and all
accessories to host medical equipment maintenance activity/MTF. Medical equipment
maintenance impounds the equipment and conduct the investigation. The designated
receiving BMET acknowledges receipt of the item (s) with accessories along with the
AF Form 4449. The receiving BMET location sends an email to AMC/SGXM:
amc.sgxm@us.af.mil acknowledging receipt accompanied by a copy of both sides of
the AF Form 4449. Note: BMETs report equipment defects as Category I or II type
complaints, in accordance with AFI 41-201, Chapter 2. Applicable forms, with
directions, are available at:
https://www.medical.dla.mil/Portal/Customer/ProductQualityDeficiency.aspx.
Completion of forms alerts AFMRA of the incident.
12.5.1.2.2. BMETs coordinate complaints involving aeromedical equipment with
AMC/SGXM DSN 312-779-6952; amc.sgxm@us.af.mil. AMC/SGXM provides
disposition action. If additional testing is required, AMC/SGXM forwards the
authorization to the AFLCMC/Aeromedical Test Laboratory for further evaluation.
AMC/SGXM facilitates shipping arrangements.
12.5.1.2.3. Complete a JPSR worksheet or DD Form 2852 and turn into the squadron
PSM. If the equipment is plugged into the aircraft or affects the aircraft, an ASAP
report in conjunction is submitted.
12.5.1.2.4. Describe the problem as accurately as possible on the above forms.
Provide circumstances leading to the event and include any pertinent information
such as O2 source, patient activity, turbulence, cabin altitude, trouble-shooting
attempted, etc. Also provide names and contact information of individuals involved.
196 DAFI48-107V1 15 DECEMBER 2020
12.5.1.2.5. When equipment malfunction affects the aircraft, notify the Pilot in
Command (PIC), and provide details of the incident to facilitate mishap reporting (to
be forwarded to wing safety).
12.5.1.3. Upon arrival, immediately send tagged equipment and all items in the
equipment chain of events (e.g., tubing, power cords, electrode sets) to the closest
supporting biomedical maintenance organization. Ensure servicing Biomedical
Maintenance Personnel are notified when equipment failed while in use on a patient or in
a plane. Medical maintenance impounds the equipment, and notifies AMC/SGXM DSN
312-779-6952; amc.sgxm@us.af.mil prior to conducting an investigation.
12.5.1.3.1. Medical maintenance inputs data on Optional Form (OF) 380, Reporting
and Processing Medical Material Complaints/Quality Improvement Report, and
notify AMC/SGXM of the incident.
12.5.1.3.2. AMC/SGXM forwards authorization to appropriate testing agency for
further evaluation. AMC/SGXM facilitates shipping arrangements.
12.5.1.4. Complete safety reporting form and turn into the squadron PSM who enters the
event into the JPSR.
12.5.1.4.1. Describe the problem as accurately as possible on the above forms.
Provide circumstances leading to the event and include any pertinent information
such as: Equipment serial number (within the event description), O2 source, patient
activity, turbulence, cabin altitude, trouble-shooting attempted, as well as location
equipment was offloaded, etc.
12.5.1.4.2. Provide names of individuals involved and contact information. When
equipment malfunction affects the aircraft, notify the PIC and provide details of the
incident to facilitate mishap reporting (to be forwarded to wing safety) and
AMC/SGXM at DSN 312-779-6952; amc.sgxm@us.af.mil.
12.5.1.5. Notify local or unit supported medical maintenance organization as soon as
possible of unusual or repeated equipment failure and safety incidents.
12.6. Procurement of Medical Materiel.
12.6.1. AMC/SGXM, in conjunction with the AE Operations Directorate, monitors policies
and procedures established for the procurement of medical materiel needed to accomplish the
AE mission. At unit level, an officer is designated to have responsibility for all medical
logistics activities. Medical allowance standards are located at the AF medical logistics
website. Contact your host MTF for resupply. Medical equipment, requiring maintenance, is
serviced by the host medical equipment repair activity or designated MERC.
12.6.2. Resupply is accomplished through the host medical logistics activity in accordance
with AFMAN 41-209 and locally established procedures.
12.6.3. Medical Equipment requiring maintenance is serviced by the host medical equipment
repair activity or designated MERC in accordance with AFI 41-201 and locally established
procedures.
DAFI48-107V1 15 DECEMBER 2020 197
12.7. ERPS Medical Logistics.

12.7.1. During peacetime operations, the property custodian orders medical and non-medical
materiel through the medical logistics function of the supporting MTF in accordance with
AFMAN 41-209 and locally established procedures. Local policies need to be followed
regarding item selection, sources of supply, and funding support. Equipment is requested
through the medical equipment management office of the supporting MTF.
12.7.2. During contingency operations, the ERPS property custodian orders supplies using
the procedures established by the responsible theater medical logistics offices, and/or as
directed in the OPORD/OPLAN for resupply procedures. These procedures, obtaining
medical re-supply and joint support activities, are the function of the TLAMM.
12.8. Recommending Allowance Standard Changes. Recommended changes to any en route
care allowance standard are emailed to the POC at the appropriate pilot unit with a courtesy copy
sent to the AMC/SGXM org box at: amc.sgxm@us.af.mil.
DOROTHY A. HOGG
Lieutenant General, USAF, NC
Surgeon General
198 DAFI48-107V1 15 DECEMBER 2020
Attachment 1
GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION
References
14 CFR 14 C.F.R. § 382.117, Must carriers permit passengers with a disability to travel with
service animals? 1 January 2012
DHA PM 6025.13, Clinical Quality Management in the Military Health System, (MHS) 1
October 2019
DoDI 4515.13, Air Transportation Eligibility, 23 October 2020
DoDI 6000.11, Patient Movement (PM), 22 June 2018
DoDI 6000.14, DoD Patient Bill of Rights and Responsibilities in the Military Health System
(MHS), 26 September 2011
DoDI 8580.02, Security of Individually Identifiable Health Information in DoDI Health Care
Programs, 12 August 2015
DoDM 6025.18, Implementation of the Health Insurance Portability and Accountability Act
(HIPAA) Privacy Rule in DoD Health Care Programs, 13 March 2019
JP 4-02, Joint Health Services, 18 September 2018
USTRANSCOM Instruction 41-02, Patient Movement of Contaminated, Contagious or
Potentially Exposed Casualties, 13 February 2019.
USTRANSCOM Handbook 41-1, Global Patient Movement Operations, 3 May 2016
AF Doctrine, Volume 1, Air Force Basic Doctrine, 27 February 2015
DAFPD 10-21, Rapid Global Mobility, 26 August 2019
DAFPD 10-29, Worldwide Aeromedical Evacuation Operations, 13 February 2019
DAFPD 48-1, Aerospace and Operational Medicine Enterprise, 7 June 2019
DAFPD 46-1, Nursing Services, 20 March 2018
DAFI 33-360, Publications and Forms Management, 6 August 2020
AFI 11-202V2, Aircrew Standardization and Evaluation Program, 6 December 2018
AFI 11-202V2 AMC Supp, Aircrew Standardization/Evaluation Program, 2 November 2020
AFI 11-202V3 AMC Supp, General Flight Rules, 14 February 2019
AFI 13-1AOCV3, Operational Procedures-Air Operations Center (AOC), 2 November 2011
AFI 13-207-O, Preventing and Resisting Aircraft Piracy (Hijacking), 4 February 2019
AFI 24-301, Ground Transportation, 22 October 2019
AFI 24-302, Vehicle Management, 21 February 2020
AFI 31-117, Arming and Use of Force by Air Force Personnel, 5 August 2020
AFI 33-322, Records Management and Information Governance Program, 23 March 2020
DAFI48-107V1 15 DECEMBER 2020 199
AFI 38-101, Manpower and Organization, 29 August 2019

AFI 41-106, Air Force Medical Readiness Program, 29 July 2020
AFI 41-201, Managing Clinical Engineering Programs, 10 October 2017
AFI 44-102, Medical Care Management, 17 March 2015
AFI 44-108, Infection Prevention and Control Program, 5 June 2019
AFI 44-119, Medical Quality Operations, 16 August 2011
AFI 46-101, Nursing Services and Operations, 30 January 2015
AFI 48-116, Food Safety Program, 11 September 2018
AFI 48-137, Respiratory Protection Program, 12 September 2018
AFI 48-107V2, En Route Critical Care, 24 November 2020
AFI 48-107V3, En Route Care Documentation, 12 April 2016
AFMAN 10-206, Operational Reporting (OPREP), 18 June 2018
AFMAN 10-2503, Operations in a Chemical, Biological, Radiological, and Nuclear (CBRN)
Environment, 14 May 2019
AFMAN 10-2909, Aeromedical Evacuation (AE) Equipment Standards, 13 March 2019
AFMAN 11-2AEV1, Aeromedical Evacuation Aircrew Training, 7 Dec 2020
AFMAN 11-2AEV3, Aeromedical Evacuation (AE) Operations Procedures, 19 October 2020
AFMAN 31-129, USAF Small Arms and Light Weapons Handling Procedures, 2 January 2020
AFMAN 41-209, Medical Logistics Support, 4 January 2019
AFMAN 44-144, Nutritional Medicine, 20 January 2016
AFMAN 44-156, Treatment of Biological Warfare Agent Casualties, 17 July 2000
AFH 10-222V1, Civil Engineer Bare Base Development, 23 January 2012
AFH 10-222V10, Civil Engineer Camouflage, Concealment, and Deception Measures, 18
February 2011
AFH 10-222V14, Civil Engineering Guide To Fighting Positions, Shelters, Obstacles And
Revetments, 1 August 2008
AFPAM 10-1403, Air Mobility Planning Factors, 24 October 2018
AFTTP 3-42.5, Aeromedical Evacuation, 23 July 2019
AFTTP 3-42.52, Aeromedical Evacuation Command Squadron (FFQCC), 1 May 2019
AFTTP 3-42.53, Aeromedical Evacuation Operations Team (FFQNT) and AEOT Manpower
Augmentation Team (FFQCM), 31 July 2019
AFTTP 3-42.57. En Route Patient Staging System, 10 Aug 2016
National Standards for Basic Life Support (BLS) for Healthcare Providers, 2019
National Standards for Advanced Cardiac Life Support (ACLS) Provider Manual, 2019
200 DAFI48-107V1 15 DECEMBER 2020
The Lippincott Manual of Nursing Practice, Philadelphia: J.B. Lippincott Co. Current Edition
Mosby Principles and Practice, Mosby’s Clinical Nursing, Current Edition
Skidmore-Roth, Linda, Mosby’s Drug Guide for Nurses, Current Edition.
Battlefield and Disaster Nursing Pocket Guide, 2nd edition; 2020
AMC Airframe Particle Testing Final Report; 30 April 2020
Adopted Forms
AF Form 579, Controlled Substances Register
AF Form 847, Recommendation for Change of Publication
AF Form 1052, Envelope for Storing Patient's Valuables
AF Form 1094, Diet Order
AF Form 1225, Informed Consent for Blood Transfusion
AF Form 1297, Temporary Issue Receipt
AF Form 3829, Summary of Patients Evacuated by Air
AF Form 3830, Patient Manifest
AF Form 3838, Do Not Resuscitate (DNR) Certification for Aeromedical Evacuation
AF Form 3841, Certificate of Release
AF Form 3851, Patient Baggage Data
AF Form 3854, Receipt for Patient’s Valuables
AF Form 3858, Aeromedical Evacuation Mission Offload Message
AF Form 3859, Turn-In of Unaccompanied Narcotics
AF Form 3899, Aeromedical Evacuation Patient Record
AF Form 3899A, Patient Movement Record Progress Note
AF Form 3899E, Patient Movement Intake/Output
AF Form 3899I, Patient Movement Medication Record
AF Form 3899N, Patient Movement Pain Adjunct Flow sheet
AF Form 4033, PMI/AE Certification Label
AF Form 4449, En Route Care Equipment Malfunction Report Tag
AFTO Form 350, Reparable Item Processing Tag
AFTO Form 394, TMDE Certification
DD Form 600, Patient’s Baggage Tag
DD Form 602, Patient Evacuation Tag
DD Form 1502, Frozen Medical Materiel Shipment
DAFI48-107V1 15 DECEMBER 2020 201
DD Form 1502-1, Chilled Medical Materiel Shipment

DD Form 1610, Request and Authorization for TDY Travel of DoD Personnel
DD Form 2163, Medical Equipment Verification Certification
DD Form 2852, Patient Movement Event/Near Miss Report
Optional Form (OF) 380, Reporting and Processing Medical Material Complaints/Quality
Improvement Report
SF 600, Health Record - Chronological Record of Medical Care
Abbreviations and Acronyms

µ—Microns
ABA—American Burn Association
ACLS—Advanced Cardiac Life Support
AD—Active Duty
AE—Aeromedical Evacuation
AECM—Aeromedical Crew Member
AECP—AE Clinical Protocol
AECS—AE Command Squadron
AECT—AE Control Team
AELT—Aeromedical Evacuation Liaison Team
AEOT—Aeromedical Evacuation Operations Team
AES—Aeromedical Evacuation Squadron
AES/CC—Aeromedical Evacuation Squadron Commander
AET—Aeromedical Evacuation Technician
AF/SG—Air Force Surgeon General
AFI—Air Force Instruction
AFMAN—Air Force Manual
AFMS—Air Force Medical Service
AFMRA—Air Force Medical Readiness Agency
AFR—Air Force Reserve
AFRC—Air Force Reserve Command
AHA—American Heart Association
ARCT—Air Refueling Control Team
AMC—Air Mobility Command
202 DAFI48-107V1 15 DECEMBER 2020
AMC/A3—AMC Directorate of Operations

AMC/A3TM—AMC Aeromedical Evacuation Training and Operations
AMC/A3VM—AMC Aeromedical Evacuation Standardization and Evaluation
AMC/SG—AMC Command Surgeon
AMC/SGK—AMC En Route Medical Care Division
AMC/SGP—AMC Aerospace Medicine Division
AMC/SGS—AMC Medical Support Division
AMC/SGX—AMC Medical and Aeromedical Evacuation, Readiness and Plans Division
AMC/SGXM—AMC Medical Equipment Force Packaging
AFSC—Air Force Specialty Code
AFTTP—Air Force Tactics, Techniques, and Procedures
AMBUS—Ambulance Bus
AMD—Air Mobility Division
ANC—Absolute Neutrophil Count
ANG—Air National Guard
AOC—Air Operations Center
AOR—Area of Responsibility
ARDS—Acute Respiratory Distress Syndrome
ARC—Air Reserve Component
ARM—Aeromedical Readiness Mission
ASAP—Aviation Safety Action Program
ASTNA—Air and Surface Transport Nurses Association
BBF—Blood and Body Fluids
BLS—Basic Life Support
BMET—Biomedical Equipment Technician
BOS—Base Operating Support
BP—Blood Pressure
BVM—Bag Valve Mask
C2—Command & Control
CAA—Commercial Air Ambulance
CC—Commander
CCATT—Critical Care Air Transport Team
DAFI48-107V1 15 DECEMBER 2020 203
CCDR—Combatant Commander
CCHF—Congo Crimean Hemorrhagic Fever
CCMD—Combatant Command
C—Collar—Cervical Collar
CDC—Centers for Disease Control and Prevention
CE—Civil Engineering
CFETP—Career Field Education and Training Plan
CIWA—Clinical Institute Withdrawal Assessment for Alcohol
CNE—Chief Nurse Executive
CNS—Central Nervous System
COMAFFOR—Commander, Air Force Forces
CONOPS—Concept of Operations
CONPLANS—Concept Plans
CONUS—Continental United States
COPD—Chronic Obstructive Pulmonary Disease
COPSA—Clinical Operations Patient Safety Alert
CPP—Cerebral Perfusion Pressure
CPR—Cardio—Pulmonary Resuscitation
CSA—Comprehensive Systematic Analysis
CVA—Cerebral Vascular Accident
DAFPD—Department of the Air Force Policy Directive
DIRMOBFOR—Director of Mobility Forces
DM—Diabetes Mellitus
DNR—Do Not Resuscitate
DoD—Department of Defense
DoDI—Department of Defense Instruction
EFB—Electronic Flight Bag
EHR—Electronic Health Record
EPSI—External Patient Safety Investigation
ERCC—En Route Critical Care
ERPS—En Route Patient Stage
ERPSS—En Route Patient Staging System
204 DAFI48-107V1 15 DECEMBER 2020
FAA—Federal Aviation Administration

FCIF—Flight Crew Information File
FFP—Fresh Frozen Plasma
FHT—Fetal Heart Tones
FiO2—Fraction of Inspired Oxygen
FN—Flight Nurse
FLACC—Face, Legs, Activity, Crying and Consolability
G—Gravitational
GCC—geographic combatant commanders
GCS—Glasgow Coma Scale
GI—Gastrointestinal
H&H—Hemoglobin and Hematocrit
HCT—Hematocrit
HCW—Health Care Worker
HELLP—Hemolysis, Elevated Liver Enzymes, and Low Platelets
HEPA—High Efficiency Particulate Air
Hgb—Hemoglobin
HIPAA—Health Insurance Portability Accountability Act
HMMWV—High Mobility Multipurpose Wheeled Vehicles
I&O—Intake and Output
ICP—Intracranial Pressure
ID—identification
ICU—Intensive Care Unit
IFK—Inflight Kits
IM—Intramuscular
I-SBAR—Identify, Situation, Background, Assessment, and Recommendation
ITV—In-transit Visibility
IV—Intravenous
IVF—Intravenous Fluids
JOA—Joint Operations Area
JPMRC—Joint Patient Movement Requirements Center
JPSR—Joint Patient Safety Reporting
DAFI48-107V1 15 DECEMBER 2020 205
JTF—Joint Task Force

kg—Kilogram
LNO—Liaison Officer
LOC—Level of Consciousness
LPM—Liters Per Minute
LR—Lactated Ringers
LRMC—Landstuhl Regional Medical Center
MA—Medical Attendant
MAAS—Motor Activity Assessment Scale
MACE—Military Acute Concussion Evaluation
MAJCOM—Major Command
MAP—Mean Arterial Pressure
MAR—Medication Administration Record
MCD—Medical Crew Director
MDG—Medical Group
MDR-TB—Mycobacterium Tuberculosis
MEFPAK—Manpower and Equipment Force Packaging System
MEMO—Medical Equipment Management Office
MERC—Medical Equipment Repair Center
MHS—Military Health Services
MII—Medical Incident Investigations
ml—Milliliter
mmHg—Millimeter of Mercury
MRA—MEFPAK Responsible Agency
MRE—Meals Ready to Eat
MTF—Medical Treatment Facility
NAF—Numbered Air Force
NATO—North Atlantic Treaty Organization
NC—Nasal Cannula
NDC—needle decompression
NG—Nasogastric
NG/OG—Nasogastric/Oral Gastric
206 DAFI48-107V1 15 DECEMBER 2020
NMA—Non-Medical Attendant
NOTAM—Notice to Airmen
NPO—Nothing by Mouth
NPWT—Negative-Pressure Wound Therapy
NS—Normal Saline
OB—Obstetrics
OCONUS—Outside the Continental United States
OG—Operations Group
OIC—Officer in Charge
OPLANS—Operational Plans
OPORD—Operational Order
OPR—Office of Primary Responsibility
ORM—Operational Risk Management
OTC—Over-The-Counter
P—Priority
PACAF—Pacific Air Forces
PACAF/SG—Pacific Air Forces/Command Surgeon
PAD—Patient Administration
PaO2—Partial Pressure of Oxygen in Arterial Blood
PAPR—Powered Air Purifying Respirator
PCA—Patient Controlled Analgesia
PE—Pulmonary Embolism
PEEP—Positive End Expiratory Pressure
PHO—Public Health Officer
PHS—Public Health Service
PIC—Pilot in Command
PM—Patient Movement
PMCC—Patient Movement Clinical Coordinator
PMI—Patient Movement Items
PMI—ATS—PMI Asset Tracking System
PMOO—Patient Movement Operations Officer
PMPS—Patient Movement Patient Safety
DAFI48-107V1 15 DECEMBER 2020 207
PMR—Patient Movement Request

PMRC—Patient Movement Requirements Center
PNB—Peripheral Nerve Block
PO—Oral/By mouth
PPE—Personal Protective Equipment
PRK—Photorefractive Keratectomy
PRN—As Needed
PS—Patient Safety
PSM—Patient Safety Manager
PSP—Patient Safety Plan
PT—Physical Training (PT)
PTSD—Post-Traumatic Stress Disorder
R—Routine
RBCs—Red Blood Cells
RCA—Root Cause Analysis
RNs—Registered Nurses
ROM—Range of Motion
RON—Remain Overnight
SAM—Self-Administering Medication
SCD—Sequential Compression Device
SG—Command Surgeon
SGH—Chief of Medical Staff
SGXM—AMC Medical Readiness Logistics/MEFPAK Management Branch
SITREP—Situation Report
SL—Sea Level
SOC—Standards of Care
SpO2—Oxygen Saturation
SSN—Social Security Number
Stan/Eval—Standards and Evaluation
TACON—Tactical Control
TAES—Theater Aeromedical Evacuation System
TB—Tuberculosis
208 DAFI48-107V1 15 DECEMBER 2020
TBI—Traumatic Brain Injury

TBSA—Total Body Surface Area
TCP—Transcutaneous Pacing
TCSG—USTRANSCOM Command Surgeon
TDY—Temporary Duty
TLAMM—Theater Lead Agent for Medical Materiel
TMDS—Theater Medical Data Store
TMO—Travel Management Office
TNCC—Trauma Nurse Core Course
TPMRC—USTRANSCOM Patient Movement Requirements Center
TPMRC-A—TPMRC—Americas
TPMRC-E—TPMRC—East
TPMRC-W—TPMRC—West
TRAC2ES—Transportation Command Regulating and Command & Control Evacuation System
TTP—Tactics, Techniques, and Procedures
U—Urgent
UOP—Urine Output
USAFE—U.S. Air Forces Europe
USAFE/AFAFRICA/SG—U.S. Air Forces Europe/USAFRICOM/ Command Surgeon
USAISR—U.S. Army Institute of Surgical Research
USAFRICOM—United States African Command
USCENTCOM—United States Central Command
USEUCOM—United States European Command
USNORTHCOM—U.S. Northern Command
USINDOPACOM—U.S. United States Indo-Pacific Command
USSOUTHCOM—U.S. Southern Command
USTRANSCOM—U.S. Transportation Command
USTRANSCOM/CC—United States Transportation Command Commander
UTC—Unit Type Code
V—Volume
VAP—Ventilator Associated Pneumonia
VCNCO—Vehicle Control Non-Commissioned Officer
DAFI48-107V1 15 DECEMBER 2020 209
VCO—Vehicle Control Officer

VFS—validating flight surgeon
VS—Vital Signs
VSB—Vacuum Spine Board
VTE—venous thromboembolism
WBCs—White Blood Cells
WRM—War Reserve Materiel
ZULU—Greenwich Mean Time (Universal Time)
210 DAFI48-107V1 15 DECEMBER 2020
Attachment 2
HELPFUL RESOURCES
A2.1. AE Resources.
A2.1.1. Aeromedical Evacuation Clinical Protocols:
https://cs2.eis.af.mil/sites/13241/sg/training/AE%20Clinical%20Protocols/Forms/AllIte
ms.aspx
A2.1.2. JTS CPG site: http://www.usaisr.amedd.army.mil/default.html
A2.1.3. Air Force Medical Equipment Development Laboratory websites:
https://eis.af.mil/cs/aeromed/default.aspx or
https://cs3.eis.af.mil/sites/27468/default.aspx
A2.1.4. Elsevier Skills Plus site:
https://kx.health.mil/kj/kx1/AFMOAEdandTraining/Pages/Elsevier-Clinical-Skills-
Plus-.aspx
A2.1.5. Battlefield and Disaster Nursing Pocket Guide (current ed.)
A2.1.6. DoD Interactive Customer Evaluation site: https://ice.disa.mil/
A2.1.7. AMC AE A3/Sg Website: https://cs2.eis.af.mil/sites/13241/default.aspx
A2.1.8. DHA MTN: https://info.health.mil/edu/mtFDIV/mtn/SitePages/Home.aspx
A2.1.9. DHA/J7 COVID Resourceshttps://info.health.mil/edu/SitePages/Home.aspx
A2.1.10. AE Documents on EFB:
https://cs2.eis.af.mil/sites/12679/Aircrew%20Pubs%20Library/Forms/Better.aspx?Root
Folder=%2Fsites%2F12679%2FAircrew%20Pubs%20Library%2FMaster%5FLibrar
y%5FVerified%2FAE&FolderCTID=0x01200021370D19BF5D9F459D8FD907C237955
A&View={701BF038-D3D9-416D-BBEC-BF178FBE44E9}
A2.1.11. Infectious Disease Documents on EFB:
https://cs2.eis.af.mil/sites/12679/Aircrew%20Pubs%20Library/Forms/Better.aspx?Root
Folder=%2Fsites%2F12679%2FAircrew%20Pubs%20Library%2FMaster%5FLibrar
y%5FVerified%2FAll%5FGlobal%2FInfectious%20Disease&FolderCTID=0x0120002
1370D19BF5D9F459D8FD907C237955A&View={701BF038-D3D9-416D-BBEC-
BF178FBE44E9}
A2.2. Helpful Patient Safety Internet Resources.
A2.2.1. Aeromedical Evacuation Portal Patient Safety:
https://cs2.eis.af.mil/sites/13241/sg/patientsafety/Patient%20Safety%20Documents/For
ms/AllItems.aspx
A2.2.2. Air Force Medical Readiness Agency Patient Clinical Quality and Safety:
https://kx.health.mil/AFMOA/ClinicalQuality/SitePages/Home.aspx
A2.2.3. Agency for Healthcare Research and Quality: http://www.ahrq.gov/
A2.2.4. Centers for Disease Control and Prevention: http://www.cdc.gov/
DAFI48-107V1 15 DECEMBER 2020 211
A2.2.5. Commission of Accreditation for Medical Transport (CAMTS)

http://www.camts.org
A2.2.6. Department of Defense Patient Safety Learning Center:
https://info.health.mil/hco/clinicsup/patientsafety/PSLCHome/SitePages/Home.aspx
A2.2.7. Institute for Safe Medication Practices: http://www.ismp.org/
A2.2.8. The Joint Commission National Patient Safety Goals:
http://www.jointcommission.org/standards_information/npsgs.aspx
A2.2.9. Joint Patient Safety Reporting LIVE Website: https://patientsafety.csd.disa.mil/
A2.2.10. National Accreditation Alliance of Medical Transport Applications (NAAMTA):
http://www.naamta.com/
A2.2.11. The Joint Commission Comprehensive Accreditation Manuals
A2.2.12. ASTNA Patient Transport Principles and Practice, 4th Ed.
A2.2.13. AHRQ; National Guideline Clearinghouse; US Dept of Health and Human
Services (www.guideline.gov).
A2.2.14. TRAINING Joint Patient Safety Reporting website:
https://psrdemotraining.csd.disa.mil/
212 DAFI48-107V1 15 DECEMBER 2020
Attachment 3
NON-MEDICAL, FAMILY OR NON-MILITARY ATTENDANT INFORMATIONAL
SHEET
Table A3.1. Aeromedical Evacuation (AE) Missions Non-Medical Attendant (Family or

Non-Military) Duty List.
AEROMEDICAL EVACUATION (AE) MISSIONS

NON - MEDICAL ATTENDANT (Family or Non-
military)
DUTY LIST
PRIMARY DUTY is to support the needs of your assigned patient
Getting ready for flight ensure all personal items are secure
Bring personal items necessary for flight
Required travel documentation (e.g., ID, passport)
Food & snacks
STAY with the patient to the final destination (if operationally feasible)
COMMUNICATE with the AE CREW for any patient needs or concerns
PLEASE ASK for assistance to help your patient with restroom needs
YOU NEED BREAKS TOO. Please COORDINATE breaks with the AE crew
AE ENVIRONMENT CAN HAVE EXTREME TEMPERATURE

FLUCTUATIONS, NOISE, AND LIMITED SPACE
TEAMWORK & COMMUNICATION ARE CRITICAL
THANK YOU FOR MAKING PATIENT SAFETY A PRIORITY
DAFI48-107V1 15 DECEMBER 2020 213
Attachment 4
MEDICAL ATTENDANT DUTY LIST
Table A4.1. Aeromedical Evacuation (AE) Missions Medical Attendant Duty List.
AEROMEDICAL EVACUATION (AE) MISSIONS

MEDICAL ATTENDANT
DUTY LIST
PRIMARY DUTY IS TO SUPPORT THE NEEDS OF YOUR ASSIGNED
PATIENT(S):
 Getting ready for flight--ensure ALL personal items are secure
prior to takeoff
 If you are on orders, your attendant time is considered “ON
DUTY”
 Stay awake throughout flight unless relieved by an AE aircrew
member—coordinate breaks with the AE crew
 Stay with the patient to the destination
 Communicate all concerns immediately to an AECM
 Ask for assistance to help your patient with restroom needs
BRING personal items necessary for flight:
 Required travel documentation (e.g., ID, passport, orders)
 Food & snacks
REVIEW assigned PATIENTS MEDICAL HISTORY prior to mission
 Know your patients and anticipate their potential needs
 ENSURE PATIENT PREPARATION IS COMPLETE prior
to flight including:
 All necessary equipment, supplies and medication are available
for the patient
 Patient‘s 3899 paperwork is complete (orders, medication
record, etc.)
 RECEIVE PATIENT HAND-OFF report from releasing
facility
 Ask questions if information is not complete or clear
DOCUMENTATION on AF Form 3899 is your responsibility
 Sign all documentation & follow signature with “medical
attendant”
 Review documentation requirements for patient’s medical
condition throughout transport with sending facility nurse or
flight nurse
214 DAFI48-107V1 15 DECEMBER 2020
MEDICATION ADMINISTRATION & DOCUMENTATION is your

responsibility
 If NOT certified to administer medications, notify flight nurse

DAFI48-107V1 15 DECEMBER 2020 215
Attachment 5
NON-MEDICAL ATTENDANT DUTY LIST (MILITARY)
Table A5.1. Non-Medical Attendant Duty List (Military).

NON-MEDICAL ATTENDANT DUTY LIST (MILITARY)
PRIMARY DUTY is to support the needs of assigned patient

 Getting ready for flight ensure all personal items are secure
 If you are on orders, your attendant time is considered “ON
DUTY”
BRING personal items necessary for flight
 Required travel documentation (e.g., ID, passport, orders)
 Food & snacks
STAY with the patient to the destination
COMMUNICATE with the AE CREW for any patient needs or concerns
ASK for assistance to help your patient with restroom needs
COORDINATE breaks with the AE crew
216 DAFI48-107V1 15 DECEMBER 2020
Attachment 6
PATIENT PREP CHECKLIST
Figure A6.1. Example Patient Preparation Checklist.

DAFI48-107V1 15 DECEMBER 2020 217
Attachment 7
PATIENT MOVEMENT INPATIENT HANDOFF CHECKLIST – FRONT
Figure A7.1. Patient Movement (I-SBAR) Handoff Inpatient Checklist (Front).

218 DAFI48-107V1 15 DECEMBER 2020
Figure A7.2. Patient Movementnpatient Handoff I Checklist (Back).

DAFI48-107V1 15 DECEMBER 2020 219
Attachment 8
PATIENT MOVEMENT OUTPATIENT HAND-OFF CHECKLIST
Figure A8.1. Patient Movement Outpatient Hand-Off Checklist.

220 DAFI48-107V1 15 DECEMBER 2020
Attachment 9
BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK BY LEVEL OF RISK
Figure A9.1. Braden Scale For Predicting Pressure Sore Risk By Level Of Risk.
DAFI48-107V1 15 DECEMBER 2020 221
222 DAFI48-107V1 15 DECEMBER 2020
Attachment 10
BURN CENTER REFERRAL CRITERIA
A10.1. A burn center may treat adults, children, or both. Burn injuries that should be referred to
a burn center are included in Table A10.1
Table A10.1. Burn Injuries.

1. Partial thickness burns greater than 10% Total Body Surface Area (TBSA).
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
3. Third degree burns of any size in any age group.
4. Electrical burns, including lightning injury.
5. Chemical burns.
6. Inhalation injury.
7. Burn injury in patients with preexisting medical disorders that could complicate
management, prolong recovery, or affect mortality.
8. Any patient with burns and concomitant trauma (such as fractures) in which the
burn injury poses the greatest risk of morbidity or mortality. In such cases, if the
trauma poses the greater immediate risk, the patient may be initially stabilized in a
trauma center before being transferred to a burn unit. Physician judgment is
necessary in such situations and is in concert with the regional medical control
plan and triage protocols.
9. Burned children in hospitals without qualified personnel or equipment for the
care of children.
10. Burn patients requiring mechanical ventilation and/or ERCC transport.
11. Burn injury in patients who require special social, emotional, or rehabilitative
intervention.
Table A10.2. Severity Determination.

First Degree red sometimes
(Partial Thickness) painful.
Superficial
Second Degree blistered swollen. Very
(Partial Thickness) painful.
Skin may be red
Third Degree (Full charred or translucent no pin prick
Thickness) Whitish sensation in
burned area.
DAFI48-107V1 15 DECEMBER 2020 223
Figure A10.1. Percentage Total Body Surface Area.

224 DAFI48-107V1 15 DECEMBER 2020
Attachment 11
MILITARY ACUTE CONCUSSION EVALUATION
A11.1. Military Acute Concussion Evaluation should be completed at the MTF or ERPS prior to
flight. Not an in-flight requirement.
Table A11.1. Military Acute Concussion Evaluation.

Evaluation Description Score
History Mechanism of injury, amnesia, loss of
consciousness, and symptoms None
Neurological Eyes: Pupil response and tracking None
Screening
Verbal: Speech fluency and word
finding
Motor: Pronator drift (both arms

extended shoulder level, palms
upwards, eyes closed), gait/
coordination
Immediate A brief repeated list learning test. /15
Memory
A list of five words is read once and
then the patient is asked to repeat the
list back, as many words as they can
recall in any order.
Repeat 2 more times for a total of

three trials, even if the patient scores
perfectly on the first trial. (one word
= one point)
Orientation One point for each: Month, Date, /5
Time, Day of Week, Year
Concentration Reverse Digits: Patient restates a /5
string of numbers (lengths of 3, 4, 5, 6
digits), in reverse order. Two attempts
allowed per string: successful string =
one point
Reverse Months: Patient states the

months of the year in reverse order
(one point if correct)
DAFI48-107V1 15 DECEMBER 2020 225
Delayed Recall Patient is asked to repeat back /5

the original list of five words, as
many words as they can recall in any
order. One point for each recalled
word
TOTAL SCORE /30
A11.2. MACE scores below 25 may represent clinically neurocognitive impairment requiring
further evaluation for a more serious brain injury.
226 DAFI48-107V1 15 DECEMBER 2020
Attachment 12
ALCOHOL WITHDRAWAL ASSESSMENT SCORING GUIDELINES
Figure A12.1. Alcohol Withdrawal Assessment Scoring Guidelines.

DAFI48-107V1 15 DECEMBER 2020 227
Attachment 13
PAIN ASSESSMENT SCALES
A13.1. Wong-Baker.
Figure A13.1. Wong-Baker.
A13.2. The above figure is Wong's Clinical Manual of Pediatric Nursing, 8e (Clinical Manual of
Pediatric Nursing (Wong)) Spiral-bound – September 1, 2011.
228 DAFI48-107V1 15 DECEMBER 2020
Figure A13.2. Face, Legs, Activity, Crying and Consolability (FLACC).
A13.3. The Above Figure is Hicks CL et al The Faces Pain Scale-Revised: toward a common
metric in pediatric pain measurement. Pain, 2003;93:173-183.
DAFI48-107V1 15 DECEMBER 2020 229
Figure A13.3. Defense and Veterans Pain Rating Scale.
Figure A13.4. DoD/VA Pain Supplemental Questions.

230 DAFI48-107V1 15 DECEMBER 2020
Attachment 14
AIRCRAFT AIRFLOW
Table A14.1. Aircraft Airflow.

Aircraft Air Flow Direction *Post- Is there
Type Mission safe space
Time on aircraft
Required for w/o
Airing Out. respiratory
protection
C-17 Top to Bottom; aft to forward; 90 minutes No
air is mixed circularly;
minimum 6ft distance
KC-135 Top to bottom; forward to aft 60 minutes No
while in-flight. No movement
on the ground.
C-130 Top to Bottom; aft to forward; 60 minutes No
air is mixed circularly;
minimum 6ft distance
C-5 Forward to aft. 60 minutes No
Cargo/Passenger and Cockpit
all on separate HVAC systems
KC-46 Top to bottom, forward to aft 60 minutes No
while in-flight; no
recirculation.
KC-10 Top to bottom/forward to aft to 60 minutes Yes
wing outflow valves, then
stagnant aft to outflow valves
C-21 Aft to forward 15 minutes No
C-12 Forward to aft 20 minutes No
w/engine
running
continuously
Notes:
1. 0.3 PFU/m3 indicates ventilation times required for aerosolized virus
concentration to reach an exposure concentration for a three hour exposure
at a respiration rate of 19L/min. (corresponding to light physical activity)
required to reach the estimated negligible biological military exposure
guideline (BMEG) dose of one PFU.
2. All doors are closed during ventilation. All air exchange is performed
by the aircraft ventilation system. No additional sources of air exchange
DAFI48-107V1 15 DECEMBER 2020 231
impact aircraft ventilation. This enables more accurate timing of

ventilation.
3. Deviations from air exchange times may be superseded with MDS-
specific guidance provided by the respective SPO.
4. Reference AMC Novel Coronavirus 2019 Patient Movement Plan
(PMP) or the most current PMP on the Electronic Flight Bag.
232 DAFI48-107V1 15 DECEMBER 2020
Attachment 15
RESPIRATORY DISEASE MISSION PLANNING ALGORITHM
Figure A15.1. Respiratory Disease Mission Planning Algorithm.

DAFI48-107V1 15 DECEMBER 2020 233
Attachment 16
PATIENT MOVEMENT PATIENT SAFETY EVENT REPORTING EXAMPLES
A16.1. The following is a guide to show examples of event reporting within the patient
movement system. This is not an all-inclusive list .
Table A16.1. Event Reporting Guide.

Event Type Description Examples
Anti-Hijack Completed Incorrectly Part of anti-hijacking not
completed or completed incorrectly
Not Completed Anti-hijacking not completed
Equipment Not Approved for Flight Equipment not approved for flight
and NO waiver obtained
Failure/Malfunction Equipment malfunctions within the
AE system. INCLUDE NAME,
MODEL NUMBER, SERIAL
NUMBER AND DETAILED
DESCRIPTION of malfunction.
Include where the equipment was
turned in. Ensure an AF Form 4449
is completed.
Infection Control Blood or Body Fluid Any exposure to blood/body fluids
Exposure
Precautions Not Infection control precautions not
Observed followed with infectious patients.
Patient Injuries Actual Environmental injuries in/around
aircraft resulting in actual harm to
a patient.
Falls Any event resulting in a patient
falling or litters carry issues.
Medication Narcotics Not Accounted Narcotics not accounted for at any
For, count incorrect, not point within the AE system.
counted, lost, or stolen
Med Error Wrong: Dose, medication, time,
route, or patient while the patient is
in transit
PCA/PNB Issue Not locked
No handoff
Incorrect Dose
Incorrect settings
Tubing not labeled
Self-Administration Issues associated with SAM
(SAM) Issue patient. To include but not limited
to: pt. took medication incorrectly,
meds in checked bag, lost, or
234 DAFI48-107V1 15 DECEMBER 2020
forgot medication
Patient Cardiac/Respiratory SOB, Arrhythmia, etc.

Unexpected Issue
Status Change
Death in flight Self-explanatory
Death within 24 hours of Self-explanatory
AE movement

Patient Unplanned Desaturation Desaturation with no PRN orders
Unexpected
Status Change
(cont.)
Unplanned Nausea/vomiting with no PRN
Nausea/Vomiting orders
Unplanned or unexpected Unplanned pain with no PRN
Pain orders or unexpected pain
Seizures Self-explanatory
Mental Health Changes Self-Injury, Anxiety, etc.
Vital Sign Changes Fever, Blood pressure, Heart Rate,
Respirations, etc.
Other Patient Status Status changes not planned for or
Change not listed above unexpected
Patient Attendant Attendant not prepared or no
Preparation Issues attendant provided
Treatment Not Done No IV, not premedicated,
Prior To Flight assessment not done, inappropriate
footwear, 1A/1B not prepared
properly, etc.
Equipment/Supply Issues Not provided, part/attachment
issues, inspection/AE certification
sticker issue, not requested, etc.
Medication Med not provided, Non-SAM with
medication, med reconciliation
issue, insufficient supply of
medication, incorrect dose
supplied, etc.
Orders No orders/partial orders, orders
incorrect, orders not signed,
conflicting/confusing orders, etc.
DAFI48-107V1 15 DECEMBER 2020 235
Paperwork/Records 3899 missing-all/part, 3899 issue,

no ID band/Card, patient data
incorrect, problems with
orders/travel documents (e.g., visa,
passport, military orders) issue, No
allergy band, etc.
Meals Meals not provided, meal issue,
etc.
Documentation Med given not documented/signed
off, documentation incomplete,
transcription error, medication
response not documented, MAR
documentation issue, date/time
issue, etc.
Communication Patient Handoff Inaccurate/incomplete report,
handoff not done, medication
handoff issue, inadequate
personnel, no record transfer, etc.
Notification Issue Notification not made, no
Command and Control (C2)
notification, language barrier, etc.

Operational Aircraft Emergency Smoke/fire, pressurization issues,
Issues related to w/Patients Only rapid decompression, emergency
patients landing, etc. involving patients
Mission/Crew/Equipment In-flight care issues, AE did not
provide equipment, equipment
securing issues, preflight/function
check issue, AE equipment (not
life support equipment)/supply
issue, etc.
Transportation Delayed transport/no show. K-
Loader/HDPLP issue, insufficient
transportation, ambulance transport
issue, etc.
Delays Only if the required timeline for
patient movement precedence is
not met or an impact to the patient.
236 DAFI48-107V1 15 DECEMBER 2020
Attachment 17
AE PATIENT AND CUSTOMER SATISFACTION SURVEY
Figure A17.1. AE Patient And Customer Satisfaction Survey.

DAFI48-107V1 15 DECEMBER 2020 237
Attachment 18
EN ROUTE CARE EQUIPMENT MALFUNCTION REPORT TAG
Figure A18.1. En Route Care Equipment Malfunction Report Tag.

238 DAFI48-107V1 15 DECEMBER 2020
Figure A18.2. En Route Care Equipment Malfunction Report Tag (Back).

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BY ORDER OF THE DEPARTMENT OF AIR FORCE

SECRETARY OF THE AIR FORCE INSTRUCTION 48-107, VOLUME 1

EN ROUTE CARE AND AEROMEDICAL

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

ACCESSIBILITY: Publications and forms are available on the e-Publishing website at

OPR: AMC/SGK Certified by: AMC/SG

Chapter 1—PROGRAM OVERVIEW 9

1.1. Mission Description. ................................................................................................ 9

Chapter 2—OPERATIONAL AND ADMINISTRATIVE ROLES AND

2.1. United States Transportation Command. ................................................................. 11

2.2. Air Force Surgeon General (AF/SG). ...................................................................... 11

2.3. Air Mobility Command. .......................................................................................... 11

2.4. Pacific Air Forces Command Surgeon (PACAF/SG). ............................................. 16

2.6. Wing Commander. ................................................................................................... 16

2.7. Flight Surgeon.......................................................................................................... 17

2.8. Patient Staging and En Route Patient Stage............................................................. 18

2.9. Contingency Operations. ......................................................................................... 18

2.10. AE Squadron UTC Structure. .................................................................................. 19

2.11. Force Protection. ...................................................................................................... 20

Chapter 3—REQUESTING AE PATIENT MOVEMENT THROUGH PMRC 22

3.1. Patient Movement Considerations. .......................................................................... 22

3.2. Requesting AE for Patients. ..................................................................................... 22

3.3. Local Flight Surgeon. .............................................................................................. 23

3.4. Submitting a PMR for Validation and Movement. .................................................. 24

Table 3.1. Minimum Requirements to Enter a Patient Movement Request. ............................. 24

3.5. Determining Movement Precedence. ....................................................................... 26

3.6. Special Category Patients. ....................................................................................... 27

3.7. Determining Patient Classification. ......................................................................... 27

Table 3.2. Patient Classification. .............................................................................................. 29

3.8. PMR Validation and Acceptance for Flight............................................................. 30

3.9. Patient Movement Operations.................................................................................. 30

3.10. Validating Flight Surgeon (VFS). ............................................................................ 31

3.11. TRAC2ES. ............................................................................................................... 32

Chapter 4—ORIGINATING AND DESTINATION FACILITY 33

4.1. General Information. ................................................................................................ 33

4.2. MTFs and ERPS responsibilities. ............................................................................ 33

4.3. Theater Medical Data Store. .................................................................................... 33

4.4. Travel Authorizations. ............................................................................................. 33

Table 4.1. TCSG. ...................................................................................................................... 33

4.5. Transportation. ......................................................................................................... 34

4.6. Documentation and Transfer of Patient Records. .................................................... 34

4.7. Mission Coordination. ............................................................................................. 35

4.8. Accountability. ......................................................................................................... 35

4.9. Entry Requirements. ................................................................................................ 35

4.10. Patient Safety Events/Near Miss Events. ................................................................. 35

4.11. RON Patients. .......................................................................................................... 35

4.12. MTF Support Requirements for the Co-Located ERPS........................................... 35

Chapter 5—EN ROUTE PATIENT STAGING SYSTEM (ERPSS) 38

5.1. En Route Patient Stage (Facility)............................................................................. 38

5.2. Roles and Responsibilities. ...................................................................................... 38

5.3. Vehicles. .................................................................................................................. 39

5.4. Interface with MTFs/Other Agencies. ..................................................................... 39

5.6. Expeditionary Medical Logistics. ............................................................................ 40

5.7. ERPS Facility Administration.................................................................................. 40

5.8. Mission Launch and Recovery................................................................................. 41

5.9. Reports and Communication.................................................................................... 42

Chapter 6—PATIENT PREPARATION 43

6.1. Overview of patient preparation. ............................................................................. 43

6.2. Litters. ...................................................................................................................... 43

6.3. Clothing the Patient. ................................................................................................ 43

6.4. Equipment and Supplies. ......................................................................................... 44

6.5. General considerations for attendants. ..................................................................... 44

6.6. Baggage. .................................................................................................................. 45

6.7. Anti-hijacking. ......................................................................................................... 46